Highlights

Nonbeneficial CPR at the end of life

A newly revised policy from the College of Physicians and Surgeons of Ontario requires consent for physicians to withhold cardiopulmonary resuscitation (CPR), regardless of the clinical situation. This new requirement would prevent physicians from using their clinical judgment as they would for other medical treatments and is not justified by law, say Downar and colleagues. See Commentary, page 245

Stroke risk early in α-blocker therapy

Use of α-blocker therapy was associated with an increased risk of ischemic stroke during the first three weeks of treatment. Using claims data for 7502 men from Taiwan’s National Health Insurance Research Database, the authors found this risk to be greater among men not taking other antihypertensive medications. The authors recommend caution when prescribing these medications to patients who are not taking other antihypertensive medications. See Research, page 255

Opioid deaths identified by ICD10 data

Readily available national vital statistics data can be used to study prescription opioid–related mortality. Using ICD 10 codes, the authors compared five combinations of codes against coroners’ reports and found sensitivities ranging from 72% to 89%. Despite some limitations, these data may facilitate the implementation of national surveillance and monitoring strategies, say the authors. See Research, page E67

Internet-assisted CBT

Internet-assisted cognitive behavioural therapy has been shown to be efficacious for a range of conditions. It allows easier and quicker access to therapy, with lower cost and greater convenience than traditional face-to-face treatment. Gratzer and Khalid-Khan review evidence from randomized trials and systematic reviews to present an overview of the usefulness of this e-health innovation. See Review, page 263

Constipation

An otherwise healthy 40-year-old woman presents with infrequent bowel movements and bloating. What investigations does she require, if any? Is it important to distinguish between irritable bowel syndrome and constipation? In this Choosing Wisely Canada article, the authors review the diagnosis and management of constipation. See Decisions, page 277

Chronic spontaneous urticaria

Chronic spontaneous urticaria, which lasts more than six weeks, can cause substantial morbidity, negatively affecting sleep, work, school and social activities. This case of a 63-year-old man with chronic spontaneous urticaria highlights advances in the assessment and management of this often difficult-to-treat condition. See Cases, page 279

Cauda equina syndrome

Most patients with cauda equina syndrome are men with a history of chronic low-back pain. However, up to 30% of patients may present without back pain. This syndrome represents a surgical emergency that can progress to paraplegia with rectal and urinary incontinence if treatment is delayed. See Five things to know about …, page 284

Terra firma–forme dermatosis

A seven-year-old girl had brown dirt-like lesions on her neck and arms that did not respond to vigorous washing or corticosteroids. The lesions disappeared completely after they were rubbed with a 70% isopropyl swab, confirming the diagnosis. See Clinical images, page 285

In ways of knowing medicine

Evidence-based medicine provides explicit and — it is claimed — objective procedures for assembling and evaluating the evidence for or against a medical intervention. But where do translational medicine, narrative medicine, and personalized/precision medicine fit in to the picture? Miriam Solomon explores how they complement each other. See Medicine and society, page 289