2002: Year in Review

The material for this "Year in Review" was provided by the Canadian Medical Association based on articles from the Canadian Medical Association Journal (Vols. 166 and 167).

ABORIGINAL HEALTH

CVD epidemic predicted

Given present trends, an epidemic of cardiovascular disease (CVD) can be anticipated in Canada's Aboriginal population unless current risk factors are addressed. A study comparing Aboriginals and people of European ancestry found significantly more Aboriginals had a history of diabetes, hyperlipidemia and hypertension, as well as a family history of myocardial infarction. Diabetes was newly diagnosed in 12% of the Aboriginal participants, as compared with 6% of the European ancestry group. More than half the Aboriginal subjects had a body mass index above 30 and about 40% were smokers, as compared with 15% of the European ancestry group. The authors recommend that smoking-cessation and weight-reduction programs be encouraged. As well, attempts should be made to replicate in an Aboriginal population the results of recent studies showing that lifestyle modification can delay the development of diabetes in those with impaired glucose tolerance. To facilitate the success of CVD risk-reduction programs, the Aboriginal population must be included in their development and implementation. CMAJ 2002;166(3):355

Methadone maintenance in prison In an attempt to curb rising HIV and hepatitis C infection rates and to lower recidivism rates, federal prisons have begun offering methadone maintenance treatment (MMT) to any prisoner with an opiate addiction. The Correctional Service of Canada expanded access to MMT in federal prisons May 2, 2002. It estimates that up to 800 prisoners may enter the program within 3 years at an annual cost of more than $10 000 each, or a potential annual total of $8 million. The new program builds on a 1998 initiative that allowed federal prisoners to continue receiving methadone if they had been in an MMT program in the community before their arrest. CMAJ 2002;167(10):1154

BLOOD

Blood conservation underused

The use of blood conservation techniques in elective surgery reduces the risk of infection and transfusion reactions that result from using allogeneic blood products, but researchers report that use of these techniques remains low in Canada. Medical records were reviewed of 4535 patients who underwent elective orthopedic procedures at 19 Canadian hospitals between June 1998 and January 1999. Of the 4422 patients whose eligibility status was known, 2561 (57.9%) were eligible to participate in an autologous blood donation program. However, only 842 (18.6%) of the patients predonated blood, and blood-conservation techniques (reinfusion of blood lost during surgery) were used in only 2.4% of all cases. CMAJ 2002;166(3):310-14

A related commentary recommends greater cooperation among anesthetists, surgeons and transfusionists in order to take advantage of alternatives to autologous blood donation during and following surgery. CMAJ 2002;166(3):332-4

CANCER

Cancer screening continues

The Ontario government is challenging the right of a Utah-based genetics company to stop Canadian laboratories from performing predictive genetic testing for 2 breast cancer genes for which the US company holds patents. Lawyers for Myriad Genetics asserted the Salt Lake City firm's patent rights to the genetic-sequencing tests for the BRCA1 and BRCA2 genes in "cease and desist" letters sent to the Ontario and British Columbia governments last year. Publicly funded laboratories in the 2 provinces, along with those in Quebec and Alberta, were using the tests to screen for hereditary breast and ovarian cancer. CMAJ 2002;166(4):494

Genital warts and cervical pathology

Women with external genital warts may be at increased risk of harbouring the subtypes of human papillomavirus (HPV) that predispose them to cervical dysplasia and cancer. Given that Pap smears are imperfect at detecting cervical dysplasia, researchers reviewed the charts of 64 consecutive women presenting with external genital warts to an STD clinic to determine whether colposcopy is warranted in such cases. The authors found that the sensitivity of the Pap smear for detecting any grade of cervical intraepithelial neoplasia was only 39% and the specificity was 68%. The sensitivity of the Pap smear for detecting high-grade dysplasia was 80% and the specificity was 69%. The authors suggest that Pap smears may be insufficient for screening women with external genital warts for lower grades of dysplasia. CMAJ 2002;166(6):598-9

No hormone replacement therapy after breast cancer

Based on a systemic review of the available evidence, researchers recommend against the routine use of hormone replacement therapy (HRT) in women who have had breast cancer. They also recommend that physicians encourage women with a previous diagnosis of breast cancer who request HRT to consider the alternatives. CMAJ 2002;166(8):1017-22

Prostate cancer incidence and mortality

Since the early 1990s, rates of death from prostate cancer have declined and there is speculation that this may be due to the advent of prostate-specific antigen (PSA) screening in the late 1980s. Researchers tested this hypothesis by studying data from cancer incidence and mortality databases in Quebec. They identified 15 groups of men over age 50 and calculated the change in prostate cancer incidence rates between 1989 and 1993 (the year when the rate peaked) for each group. The change in prostate cancer mortality for each group between 1995 and 1999 was also calculated. Between 1989 and 1993 the incidence rate increased in all 15 groups, by 22% to 178%, and between 1995 and 1999 the rate of death decreased in 11 of the 15 groups, by 3% to 50%. Using weighted linear regression analyses, they showed that the groups with large increases in detection did not necessarily experience large mortality decreases. Thus, greater rates of detection early in the 1990s (presumably owing to PSA screening) did not seem to correlate with larger declines in mortality by the late 1990s. CMAJ 2002;166(5):586-91

A related commentary suggests that additional randomized trials are needed to identify whether PSA screening is truly beneficial at a population level. CMAJ 2002;166(5):600-1

CLINICAL PRACTICE

Ankle Rules efficacy

Decision-making rules such as the Ottawa Ankle Rules have been widely adopted because of their potential for safely reducing a patient's exposure to costly and unnecessary testing such as x-rays. The question is, how effective are these rules? Surgical residents at medium-sized community hospital in Amsterdam performed a history and physical examination of 690 consecutive patients with ankle injuries and completed a standard data collection form that incorporated elements of both the Ottawa and Leiden (developed in 1991) ankle rules. The physicians then reported whether they felt a radiograph was necessary, and all patients underwent ankle radiography. The authors found that the sensitivity and specificity of the physician's judgment was 89% and 26% respectively for the Ottawa rules, 80% and 59% for the Leiden rule and 82% and 38% for the physicians' judgement. Eight fractures were missed with the Ottawa rules, 15 fractures were missed with the Leiden rule, and the residents missed 13 fractures. The authors conclude that with the aid of structured data collection, physician's judgement was similar to existing ankle rules in terms of sensitivity and ability to safely reduce the number of radiographic examinations. CMAJ 2002;166(6):727-33

Carotid endarterectomy

Occlusion of the carotid artery from atherosclerotic disease results in ischemic stroke in many patients. Surgery may help some patients, but who is a good candidate and who isn't? Researchers reviewed the appropriate uses of carotid endarterectomy. Symptomatic patients with at least 70% stenosis of the internal carotid artery are at greatest risk of stroke and may benefit the most from the procedure. Patients with 50%-69% stenosis experience less of a benefit from the procedure, and for some, including women and patients with transient monocular blindness only, the harms may outweigh the benefits. Patients with less than 50% stenosis and those who are asymptomatic do not appear to benefit. CMAJ 2002;166(9):1169-79

Decline in comprehensiveness

Recent studies have suggested that comprehensiveness and continuity of primary care, long held to be the key principles of family medicine, have declined steadily over the past decade. A researcher used Ontario Health Insurance Plan billing data to track the participation rates of general practitioners and family physicians in 6 nonoffice settings such as hospital visits, house calls, emergency work etc. He found that the proportion of physicians practising exclusively in their offices increased from 14% in 1989/90 to 24% in 1999/00. In 1999/2000, recent graduates were more likely than older physicians to be involved in emergency medicine work (40% versus 5%), whereas older physician were more likely than recent graduates to make house calls and nursing-home visits (57% and 20% versus 37% and 11%). The author concludes that there has been a decline in the provision of comprehensive care by Ontario's general practitioners and family physicians, stating that many may conclude that desire for quality family time and the increased complexity of medical care dictates that the "ideal of the super-FP" who can do everything is unrealistic. Alternatives such as group family practices or "family practice networks" can help meet the need for comprehensive primary care, he finds. CMAJ 2002;166(4):429-34

Fatal Fridays

Friday is the most common day for patients to be discharged from hospital, yet a new study indicates that patients sent home on this day are more likely to die or be readmitted to the hospital. Researchers examined associations between discharge day, and rates of death and readmission within 30 days of discharge among adults discharged from Ontario hospitals between Mar. 1, 1990, and Mar. 1, 2000. The authors found that patients released on Fridays "were significantly more likely to have an event" causing death or readmission to hospital than patients in the reference group (people discharged on Wednesdays). The authors speculate that the increased risk may be due to delays in providing social services or to the provision of incomplete discharge information due to increased demands on hospital staff at the end of the week. The authors "suggest that clinicians keep this observation [about Friday discharges] in mind if they consider pushing to get patients home for the weekend." CMAJ 2002;166(13):1672-3

New hypertension recommendations

Canadian guidelines for the management of hypertension have been updated annually since 1999 to respond to the intense research produced in the field. Using the hypothetical case of Mrs. J, researchers for the Canadian Hypertension Recommendations Working Group discuss the most up-to-date guidelines for the diagnosis, investigation and management of hypertension. CMAJ 2002;167(6):661-8

Plasticizer an unacceptable risk

In March 2002 a Health Canada expert advisory panel recommended banning the use of medical devices containing DEHP (di-2-ethylhexyl-phthalate) in newborns, prepubertal males and patients receiving intensive intravenous therapies. DEHP, a plasticizer used to soften the polyvinyl chloride used in IV bags, tubing and other devices, has been linked in animal studies to reproductive problems, particularly a decline in sperm production. Infants receiving neonatal intensive care may receive 20 times the exposure to DEHP considered tolerable by the US Food and Drug Administration (FDA). The report recommends using alternative products for patients at "greatest risk" and calls for the labelling of all devices containing DEHP. CMAJ 2002;166(9):1200

Rules of evidence

The term "evidence-based medicine" (EBM) entered the medical lexicon in 1992 and pointed to a shift away from medical care that relied on the traditional skills of intuition and clinical experience in favour of care based on evidence derived from clinical research. Researchers conducted a qualitative study to investigate how EBM is viewed and being used in the primary care setting. They conducted 9 focus groups (3 each in rural, semi-rural and urban settings) involving a total of 50 family physicians in Nova Scotia. The authors report that evidence is influencing the decision-making of both physicians and patients, and therefore plays an important role in primary care. However, they also found that physicians often adjust the application of evidence to take into account the views, interests and needs of the patient. CMAJ 2002;166(12):1525-30

Slowing chronic renal insufficiency

The number of Canadians with end-stage renal disease will increase by approximately 6% annually through the year 2005. Given that this condition is associated with substantial illness and death, high health care costs (more than $1 billion annually) and poor quality of life, preservation of residual renal function in people with chronic renal insufficiency is an important public health objective. The authors review current strategies to delay or prevent progression of chronic renal insufficiency to end-stage renal disease. CMAJ 2002;166(7):906-7

South Asian MI profiles

South Asian Canadians (those from India, Pakistan, Sri Lanka and Bangladesh) have higher rates of myocardial infarction (MI) than Canadians of European origin. Exploring these differences, researchers studied 2 groups of patients with acute MI: 553 South Asian subjects and 553 non-South Asian subjects matched by age, sex, discharge date and hospital of admission. The groups were compared in terms of presentation characteristics, cardiac risk factors and in-hospital outcomes. On average, the South Asian patients took longer to present to hospital (3.92 versus 3.08 hours) and were more likely to have diabetes (43.4% versus 28.2%) despite having a lower mean body mass index (25.7 versus 28.0). However, they were less likely to be smokers (29.3% versus 67.8%) or have pre-existing cardiovascular disease (49.4% versus 55.0%). Despite their differences, the 2 groups had similar MI mortality and in-hospital outcomes. The authors recommend that special prevention and awareness efforts be targeted at South Asian communities. CMAJ 2002;166(6):717-22

Survival following in-hospital CPR

Contrary to the plot line of television dramas, most people do not survive following cardiopulmonary resuscitation (CPR) in hospital, say the authors of a new study. In TV medical dramas, 75% of patients survive following CPR, but these rates are 2 to 6 times higher than those in any reported study. Researchers used 2 years of records from Edmonton teaching hospitals to glean survival data and outcome details for 247 hospitalized patients who experienced witnessed and unwitnessed cardiopulmonary arrests. Among witnessed arrests, 1 in 2 patients were resuscitated, 1 in 3 survived 24 hours, 1 in 4 survived to discharge and 1 in 5 returned home. Of 104 unwitnessed arrests, only 1 patient survived to discharge. This knowledge is important for physicians, patients and families who are engaged in discussions about end-of-life care in the hospital setting. CMAJ 2002;167(4):343-8

Teaming up to reduce stroke

Although the initial treatment of an acute stroke remains a subject of both research interest and debate, it has become clear that patients who have suffered a completed event do best with careful attention from a large team of professionals in a stroke unit. Experts describe the Acute Stroke Unit at the Queen Elizabeth II Health Sciences Centre in Halifax and compare their success from 1997 through 2000 with outcomes of stroke survivors in Halifax during the 4 years before the unit was established. They report that care in the Acute Stroke Unit led to a statistically significant reduction in length of stay (at a saving of $2.1 million annually per 1000 patients treated) and to a reduction in the incidence of deep vein thrombosis. CMAJ 2002;167(6):655-60

A related commentary stresses the benefits of stroke units and multidisciplinary stroke teams and urges other centres to follow Halifax's example. CMAJ 2002;167(6):649-50

Therapy for Alzheimer's disease

Alzheimer's disease is a debilitating illness, but new medications may slow its progression in some people. An author reviews the cholinesterase inhibitor class of medications, their place in the management of Alzheimer's disease and their potential side effects. He also looks at possible future avenues for therapy. CMAJ 2002;166(5):616-23

Waiting for hip replacement

Previous waiting list studies have not properly assessed the relation between the entire wait for surgery and postoperative quality of life. It is possible that those who wait longer not only suffer more because of the greater waiting time but might also have poorer outcomes afterward. Researchers tested this hypothesis and found the length of wait for elective total hip arthroplasty is not associated with postoperative health-related quality of life (HRQOL) and mobility. However, patients who undergo the procedure within 6 months after referral have greater disability at referral, and realize greater gains in HRQOL and mobility after surgery, than patients waiting more than 6 months. Clinically important losses in HRQOL and mobility occur in patients waiting more than 6 months. CMAJ 2002;167(10):1115-21

Waiting for essential diagnostic tests

A new study has found that only 37% of patients awaiting cardiac catheterization at a regional centre in Ontario underwent their procedure within the requested timeframe. Researchers documented mortality and morbidity data for a group of 8030 patients referred for cardiac catheterization and identified predictors of cardiac events that occurred while patients were waiting for the procedure. In addition to finding that few patients underwent the procedure within the specified time, 109 patients (1.4%) had a major cardiac event while waiting and 50 died during the median wait of 27 days.

The authors suggest that these findings are benchmark for measuring the effects of increased capacity and prioritization schemes. They also say that developing central booking systems, specifying minimal acceptable criteria for cardiac catheterization, better systems to prioritize and monitor changes in patients' status and specifying maximum waiting times for patients at low risk as potential ways for reducing waiting times for cardiac catheterization. CMAJ 2002;167(11):1233-40

A related commentary states that the need for better risk stratification of both inpatients and outpatients, and for systematic monitoring of the catheterization process, has never been greater. CMAJ 2002;167(11):1247-8

COMPLEMENTARY MEDICINE

Chiropractic and vaccination

Although the Canadian Chiropractic Association and Canadian Memorial Chiropractic College (CMCC) officially endorse vaccination "for certain viral and microbial diseases," ultraconservative practitioners maintain that poorly positioned vertebrae impede the body's own natural healing power. These practitioners — known as "purpose-straight" — recommend that patients reject drugs, surgery and other invasive allopathic medical procedures in favour of chiropractic "adjustments." Researchers surveyed 467 of 621 CMCC students to determine their attitudes and sources of information about vaccination. The authors report that among first-year students, 60.7% favoured vaccination while 4.5% were against it, as compared with 39.5% and 29.4% respectively among fourth-year students. The authors state that the trend to negative attitudes toward vaccination was almost "exclusively limited" to students who favoured informal sources of vaccine information over the "core CMCC lectures given by faculty, which had a relatively positive attitude toward vaccination." CMAJ 2002;166(12):1531-4

A related commentary states that antivaccine attitudes are not the norm and recommends that reliable and accessible information about vaccines be made more widely available so that myths and invalid claims about safety can be properly evaluated. CMAJ 2002;166(12):1544-5

Ephedra products recalled

Health Canada has announced a voluntary recall of some products containing ephedra and ephedrine, even though their sale has long been prohibited in this country. But herbal supplements have been linked to at least 60 adverse events in Canada and 81 deaths in the US. CMAJ 2002;166(2):225

Health Canada warns that some over-the-counter supplements used to increase energy and promote weight loss and bodybuilding pose a serious risk to health. The warning applies to supplements containing the herb ephedra or its alkaloid derivative, ephedrine; in Canada, ephedrine is authorized for use only as a nasal decongestant. CMAJ 2002;166(5):633

Herbal kava caution

Health Canada advises that products containing kava should not be used. The drug is used in a variety of herbal and homeopathic preparations to induce relaxation, treat anxiety or induce sleep. Health Canada is unaware of any kava-related adverse events in Canada, but the US Food and Drug Administration recently issued a warning letter about 25 reports of serious liver toxicity in Germany and Switzerland, including cases of cirrhosis, hepatitis and liver failure. It also cited a case in the US of a previously healthy young woman who required a liver transplant after using a kava-containing supplement. CMAJ 2002;166(6):777

Link between chiropractic, stroke

More than 60 Canadian neurologists have issued a statement warning that chiropractic neck manipulation can cause stroke and death. The neurologists and the Canadian Stroke Consortium caution that chiropractic manipulation involving the neck can cause arterial dissection. They call for a ban on manipulations involving infants and children. But the Canadian Chiropractic Association says that neck manipulations help relieve chronic back pain and migraine. CMAJ 2002;166(6):794

More provinces protect MDs

The number of provinces with laws protecting physicians who practise alternative forms of medicine is growing. In spring 2002 British Columbia joined Alberta and Ontario in having legislation designed to protect these physicians from disciplinary action solely because they offer these therapies. In all 3 provinces the legislation began life as a private member's bill. CMAJ 2002;166(3):367

Popularity rises

Data from Statistics Canada's National Population Health Survey indicate that Canadians' use of alternative health care practitioners increased steadily in the late 1990s, with the proportion consulting alternative providers rising from 15% in 1994/95 to 17% in 1998/99. Although small, the increase is considered statistically significant. CMAJ 2002;166(3):366

Potential dangers of chiropractic manipulation

A long-awaited coroner's inquest into the stroke-related death of a 45-year-old Ontario woman has renewed debate about the potential dangers of chiropractic manipulation. The inquest, which began in Toronto in April 2002, focussed on the role cervical manipulation may have played in the 1996 death of Lana Dale Lewis. Shortly after she began receiving chiropractic treatment for migraine, Lewis had the first of 2 strokes; the second led to her death in August 1996, 17 days after the initial treatment. Her family says she began showing signs of dizziness and memory loss days after the first treatment. Lawyers for the Canadian Chiropractic Association and the Canadian Memorial Chiropractic College maintain that cervical manipulation played no role in her death. A disabled 67-year-old man from Waterloo, Ont., has also filed suit against his chiropractor, claiming that a cervical manipulation had left him partly blind and unable to walk. Meanwhile, the Manitoba government joined a trend for the profession by cutting chiropractic coverage by 30% and eliminating it entirely for children. CMAJ 2002;166(12):1576

Spinal manipulation: safety uncertain

Spinal manipulation is used by chiropractors, osteopaths, physicians and physiotherapists to treat musculoskeletal problems such as back and neck pain, but a commentary points out that there is little evidence to demonstrate that it has any specific therapeutic effects. There is, however, convincing evidence that it is associated with frequent, mild adverse effects, such as local discomfort, headache, fatigue and radiating discomfort, as well as serious complications, including neorological complications, of unknown incidence. The author concludes that it seems debatable whether the benefits of spinal manipulation outweigh its risks and that definitive, prospective studies are needed. CMAJ 166(1):40-1

CONTROVERSIES

"A completely preventable death"

Joshua Durnford was the third Ontario teen with complex physical, developmental and psychiatric needs to die while in care of the province in the past 5 years. On Feb. 15, 2000 — aged 18 years but with a mental age physicians placed at 12 years — he died in an adult detention centre. He had complained of feeling unwell for 4 days but received no treatment. His death from neuroleptic malignant syndrome was "completely preventable," a physician testified at the subsequent inquest. The Office of Child and Family Service Advocacy, an arm's-length agency that watches out for children in government care, says the number of these complex cases is growing. Three years ago, there were about 200 such cases, many involving children with neurologic disorders; today there are 400. The problem, says the advocacy group, is that there's no place for these children. CMAJ 2002;166(7):944

Ban car cellphone use: jury

The jury for Canada's first inquest involving deaths following cellphone use while driving has called for a ban on such use, even though the Canada Safety Council says better education is the answer. The inquest looked into the deaths of Richard Schewe, 31, of Ajax, Ont., and his 2-year-old daughter, Mikaela, at a railway crossing on May 7, 2001. Schewe was talking on a cellphone when he drove through flashing lights at a level crossing and into the path of a train. In September the jury concluded that Ontario should consider banning cellphone use while driving, except in emergencies. It also called for a task force to develop education and public-awareness campaigns to combat driver distraction. CMAJ 2002;167(8):913

Coroner considers second cisapride inquest

A coroner's inquest may be held into the deaths of 8 patients at the same hospital who had been prescribed the antireflux medication cisapride. The drug was withdrawn from the Canadian market in August 2000. Information about the deaths at the Joseph Brant Memorial Hospital in Burlington, Ont., emerged after a hospital pharmacist, Sana Sukkari, made a report to Health Canada about the cases last year. All 8 patients, who ranged in age from 54 to 84, were seriously ill and received treatment in the intensive care ward between June 1998 and March 2000. Treatment with cisapride was contraindicated in all cases. CMAJ 2002;166(8):1075

Elective surgery and quality of life

The appropriateness of elective surgery, and access to it, has stimulated great debate in Canada. Investigators examined the indications for surgery and the health-related quality of life (HRQOL) of 5313 consecutive patients booked for 1 or more of 6 elective procedures in Vancouver. The authors report that the most striking improvements in HRQOL were seen among patients who underwent lumbar disk surgery and total hip replacement. In comparison, there was little or no change among patients who had cataract surgery, likely because many patients had relatively minor symptoms prior to undergoing the procedure. CMAJ 2002;167(5):461-6

Marijuana bill goes up in smoke

Alliance MP and physician Keith Martin introduced a private member's bill calling for the decriminalization of marijuana possession, but it was killed in April 2002 by a procedural manoeuvre. Bill C-344 would have made simple marijuana possession a minor civil offence rather than a criminal one - an idea several national organizations, including the CMA, have supported. The CMA says this would allow funds to be redirected from criminal prosecution to the treatment of addiction. Currently, someone found guilty of "simple possession" (30 g or less) of marijuana receives a criminal record, faces up to 6 months in prison and a fine of up to $1000. Martin's bill, which was introduced in May 2001, would have made a first offence punishable by a fine of $200. This would increase to $500 for a second offence and to $1000 for all subsequent ones. Martin's bill made it to second reading before a Liberal motion to refer it to a special parliamentary committee effectively killed it. CMAJ 2002;166(11):1452

Marijuana's impact on intelligence

A new study finds that light and former use of marijuana does not appear to have a long-term effect on intelligence, while heavy use appears to be detrimental. Researchers followed 70 subjects in the Ottawa Prenatal Prospective Study, and compared intelligence quotient (IQ) scores of subjects at 9-12 years of age (before initiation of marijuana use) with their scores at 17-20 years. The authors grouped subjects as nonusers, light users (fewer than 5 joints per week), former users of marijuana or heavy users. The authors found that among heavy users (more than 5 joints per week) IQ scores decreased by 4.1 points on average, while gains in IQ scores were seen among light users (mean 5.8 points), former users (mean 3.5 points), and nonusers (mean 2.6). The authors state that while there was a significant decline in IQ scores, the scores of the subjects — at a mean of 109.1 — were still above average at the young adult assessment (mean 105.1). They add that if preteen IQ had not been assessed, the subjects would have appeared to be functioning normally. The authors suggest further investigation into the cognitive consequences of both current and previous marijuana use, particularly since the popularity of the drug has been increasing over the last 4 years. CMAJ 2002;166(7):887-91

Marijuana provider lauded

A Victoria judge who praised an advocate for the medical use of marijuana says that either Parliament or the Supreme Court must resolve the legal issues surrounding the therapeutic use of the illegal drug. Provincial Court Judge Robert Higinbotham granted an absolute discharge to Philippe Lucas, who had pleaded guilty to possessing about 3 kg of marijuana. Higinbotham said Lucas had merely "provided that which the government was unable to provide: a safe and high-quality supply of marijuana to those needing it for medicinal purposes." Lucas runs the Vancouver Island Compassion Society, which provides marijuana to about 250 members who have been referred by their doctors. CMAJ 2002;167(6):679

MDs key to eliminating unfit drivers

Physicians are the key to keeping unsafe drivers off the road, an inquest jury has determined. And as they do this job, they should not engage in demographic profiling because even though impairment "is more prevalent with age," it can occur at any time. The inquest concerned the death of 42-year-old Beth Kidnie in April 2000. Kidnie, who had been out for a walk in her Toronto neighbourhood, was run over and dragged for almost a kilometre under a car driven by 84-year-old Pilar Hicks. Hicks told police that she was completely unaware she had hit anyone. At the inquest, the jury heard that Hicks had never shown signs of cognitive impairment. That is probably why the jury decided not to target elderly drivers. Instead, it asked the Ontario Medical Association and province to develop a tool to screen for any driver who poses a potential danger. CMAJ 2002;166(9):1196

Olivieri revisited

The case of Dr. Nancy Olivieri, her relationship with pharmaceutical manufacturer Apotex Inc., and her subsequent dispute with the Hospital for Sick Children and the University of Toronto has been well documented in the media and was even the subject of 2 extensive — and diametrically opposed — reviews. A commentary on the saga argues that it is not enough to say the case is closed. The authors warn those in the broader national community, and particularly those engaged in clinical research, that the circumstances that precipitated this "fiasco" are not unique to the University of Toronto or the Hospital for Sick Children and that close attention must be paid to how the saga unfolds. CMAJ 2002;166(4):448-50

A progress report from University of Toronto Dean of Medicine documents the efforts to develop a consistent framework for negotiations with industrial sponsors of academic research on behalf of the 8 university-affiliated teaching hospitals in Toronto. The Dean reports that efforts have gone well to date and he encourages other Canadian universities and hospitals to share experiences and ideas. CMAJ 2002;166(4):453-6

Stem cell rules

Health Canada has issued rules for stem cell research that will permit the study of both embryonic and adult stem cells. The Act Respecting Assisted Human Reproduction, introduced May 9, bans human cloning and the buying or selling of human sperm, eggs or embryos, or providing goods and services in exchange for them. The proposed law also prohibits paying women to act as surrogate mothers. The legislation will not permit the creation of embryos for stem cell research, but it will allow surplus embryos produced during in-vitro fertilization to be used for medical research. CMAJ 2002;166(13):1704

UK woman refused right to assisted suicide

A woman with an incurable disease has lost her bid to commit assisted suicide in the first case of its kind tried under the Human Rights Act of the United Kingdom. Diane Pretty, 42, had motoneuron disease and is paralyzed below the neck. A mother of 2, she wanted her husband to help her die when she was ready, but in Britain this is a crime. Pretty wanted assurances from the Director of Public Prosecutions that her husband would not be arraigned if he helped her die; no such assurance was provided. Pretty felt that decision, while correct under the law, contravened articles 3 and 8 of the recently introduced Human Rights Act, which bestow the right of freedom from inhuman or degrading treatment and the right to privacy of family life without interference. CMAJ 2002;166(2):232

Diane Pretty died on May 11, but only after losing her assisted-suicide case before the European Court of Human Rights. The court ruled in April that the fact assisted suicide is illegal in the UK did not constitute a breach of her rights. Pretty and her husband brought their petition to the European court after losing an appeal in Britain. Following the ruling, Pretty said the law had stripped her of her rights. The British Medical Association backed the court ruling, but noted that "it is only right that there should be periodic legal review in light of changing legislation and societal views about human rights." In another case, a 43-year-old paralyzed woman won the right to turn off the ventilator that was keeping her alive. That case, involving a former social worker identified as Ms. B, affirmed a patient's right to refuse treatment. CMAJ 2002;166(12):1578

DISEASE RESEARCH

The hockey heart study

A study suggests that recreational hockey players may be exercising too intensely and triggering dangerous cardiac responses. The researchers studied cardiac responses in 113 men over age 35 playing recreational hockey. After baseline cardiac risk factors were assessed, the subjects underwent holter electrocardiographic monitoring before, during and after at least 1 hockey game. The authors found that the maximum heart rate exceeded the target rate (calculated as 55% to 85% of the age-predicted maximum heart rate) for all subjects. The mean period that the heart rate exceeded 85% of the heart-rate maximum was 30 minutes. The authors also found that in 70.1% of the cases, heart-rate recovery was slow. CMAJ 2002;166(3):303-7

A related commentary cautions against warning off middle-aged shinny players. Instead, the author recommends that these individuals be encouraged to exercise regularly throughout the year, since that represents the best defence against a host of cardiac risk factors — including the small risk of an acute cardiovascular event during a hockey game. CMAJ 2002;166(3):331-2

ENVIRONMENTAL ISSUES

Air pollution and health

Subgroups of patients who appear to be more sensitive to the effects of air pollution include young children, the elderly and people with existing chronic cardiac and respiratory diseases such as chronic obstructive pulmonary disease and asthma. It is unclear whether air pollution contributes to the development of asthma, but it does trigger asthma episodes. Physicians are in a position to identify patients at particular risk of health effects from air pollution exposure, and to suggest timely and appropriate actions that these patients can take to protect themselves. CMAJ 2002;166(9):1161-7

Alternative to incineration

Incineration is the main method for disposing of the wide range of combustible materials that constitute biomedical waste at hospitals But there is growing concern over the inability of incineration technology to process safely the increased volumes of plastics, metals and pathogens in hospital waste. In 1985, 62% of the 137 hospital incinerators operating in Ontario were reported to be ill-equipped to handle the various components of the biomedical waste stream. However, much of the waste considered to be biomedical may be misclassified. A1992 audit at Toronto's Hospital for Sick Children found that about 80% of the biomedical waste comprised items such as paper, cans, bottles and packaging that did not belong there. Several Canadian hospitals recently implemented programs to reduce the amount of misclassified biomedical waste entering the waste stream. Over 18 months a Toronto hospital reduced the volume of biomedical waste produced each month from 14 800 kg to 6300 kg, which resulted in monthly savings of $5599. CMAJ 2002;166(3):354

Arsenic and pressure-treated wood

Several US states have banned the use of pressure-treated wood in playground structures because the wood leaches arsenic into the soil. Governments and the industry say the wood poses minimal risk, yet both the US and Canada have demanded that the industry put handling advisories on each piece of wood. Chromated copper arsenate wood, which has excellent fungicidal and insecticidal properties, is the most widely used pressure-treated lumber. CMAJ 2002;166(1):79

DDT use eliminated in North America

Mexico has stopped using DDT for malaria control. At the Health and Environment Ministers of the Americas meeting in Ottawa Mar. 4, 2002, Herñando Guerrero said elimination of the tonnes of DDT used annually is a "radical change" that involved thousands of Mexicans at a scientific, health and grassroots level. Guerrero, a director at the Commission for Environmental Cooperation of North America, said Mexico now combats malaria with a mix of biological, chemical and public-health measures. Under the new program, one Mexican state cut the incidence of malaria from 17 855 cases annually to 284 cases in just 3 years. Pilot projects using the Mexican techniques are now underway in 8 other Latin and South American countries, including Costa Rica and El Salvador, and the project may soon expand to the Caribbean. CMAJ 2002;166(10):1322

Global warming warning

A new report warning of sudden, catastrophic effects from global warming should provide an impetus for change, a leading researcher says. The report from the US National Academies' National Research Council warns that people can expect "climate surprises" in the form of "large, abrupt and unwelcome regional or global climatic events" — more droughts, floods, extreme temperatures, hurricanes and rising sea levels. The report urges "proactive policies" to reduce emissions of greenhouse gases and improve water, land and air quality. CMAJ 2002;166(8):1076

Hospital leaves huge "ecological footprint"

Hospitals have a huge impact on the environment, says the author of a study in Vancouver. She calculated a hospital's ecology footprint, a measure of how much land is needed to support the consumption of resources and production of waste by the institution. She found that Lions Gate Hospital has an ecological footprint covering at least 2841 hectares — 739 times its actual size. The city of Vancouver's footprint is 180 times its total area. CMAJ 2002;166(3):363

Kyoto ratification

Although the US and Australia show increasing reluctance to embrace it, it appears likely the Kyoto Protocol will be ratified anyway. The treaty, designed to reduce greenhouse gas emissions, must be ratified by at least 55 of the 100 countries that helped draft it, and those 55 must have been responsible for at least 55% of the world's emissions in 1990. Japan and the European Union ratified the treaty in June, and Russia and Poland have committed to doing so later this year. This means that Canada, Australia and the US aren't needed to bring it into force. The 1997 protocol calls for the reduction of greenhouse gas emissions to 6% below 1990 levels by 2012. Canadian headlines claiming that the treaty will cost $40 billion and thousands of jobs have alarmed many people, including politicians. Per capita, Canada is the second-largest greenhouse-gas producer within the Group of Eight. [Canada eventually ratified the Kyoto protocol December 11, 2002.] CMAJ 2002;167(2):180

Lead in the environment

Lead exposure can cause several chronic and debilitating health problems, especially in children. Researchers reviewed sources of lead exposure at work, in and around the home and in other settings. They discuss the hematologic, renal and neurotoxic effects of exposure to the metal. The authors also discuss the identification of affected individuals in high-risk populations, laboratory testing and ways to prevent lead exposure. CMAJ 2002;166(10):1287-92

Managing environmental health effects

Environment can have a marked impact on our health, but many physicians do not have a ready approach to recognize and manage harmful effects in patients exposed to environmental contaminants. In the first article of a CMAJ series on identifying and managing environmental health effects, researchers review toxic biological, physical and chemical exposures and describe a mnemonic tool, CH2OPD2 (Community, Home, Hobbies, Occupation, Personal habits, Diet and Drugs), to help physicians take patients' environmental exposure histories to assess those who may be at risk. CMAJ 2002;166(8):1049-55

Persistent organic pollutants (POPs)

POPs are carbon-containing chemicals that accumulate in the fat of living organisms, and increase in quantity up the food chain. They resist photolytic, biological and chemical degradation and persist in the environment, taking as long as a century to degrade. Twelve POPs, including 9 pesticides, have been identified by the United Nations Environment Programme as powerful threats to the health of humans and wildlife and have been targeted for elimination. Researchers present an illustrative case of a mother who is concerned about eating fish and wild game because her 7-year-old son has been found to have learning difficulties and she is planning another pregnancy. The authors provide advice to limit a patient's exposure to these contaminants and discuss the relevance of these exposures to the learning difficulties of the 7-year-old child and to the planning of future pregnancies. CMAJ 2002;166(12):1549-54

Pesticide bill falls short

In May, environmental groups said a long-awaited update of Canada's 33-year-old Pest Control Products Act (PCPA) is a significant move forward but it still does not go far enough in shifting Canadians away from their reliance on pesticides. Canada's current pesticide law controls approximately 6000 products, many of which were approved in the 1960s and 1970s. PCPA 2002 legislates mandatory reporting of adverse events and fines of up to $500 000. It also calls for the re-evaluation of all existing pesticides and automatic reviews every 15 years. Both the Canadian Association of Physicians for the Environment (CAPE) and the World Wildlife Federation Canada (WWFC) welcomed the new act, but want a commitment to pesticide reduction set as a broad goal. CMAJ 2002;167(1):68

Pesticide exposure

Exposure to pesticides can affect human health in a variety of ways, from acute poisoning to chronic effects including dermatitis, neurobehavioural symptoms and cancer. In the fourth article in a CMAJ series on identifying and managing adverse environmental health effects, researchers review the common sources of exposure and discuss the epidemiology of pesticide poisoning. They provide clinical information on diagnosing and managing cases of pesticide exposure, identify groups who are occupationally or biologically vulnerable and offer advice on preventing exposure. CMAJ 2002;166(11):1431-6

Physician fired over pro-Kyoto comments

An Alberta physician fired for voicing support for the Kyoto Protocol has declined an offer to return to his position. Dr. David Swann of Calgary, who was fired as chief medical officer of health by the Palliser Health Authority Oct. 2, had cited concerns about the board that oversees the health unit before making his decision. "My trust has been severely shaken during this process," he told CMAJ shortly before rejecting the offer to return in mid-October. "In a personal sense, it's a direct assault. In a professional sense, it undermines the basis on which we believe we're working under the Public Health Act. It damages the credibility I need to deal with threats to public health, and it has shaken me profoundly." CMAJ 2002;167(10):1156

ETHICS

No laws on stem cell research

A federal agency has released guidelines on embryonic stem cell research, but private sector researchers will continue to operate without any rules until legislation is in place. The guidelines, issued in March by the Canadian Institutes of Health Research (CIHR), take effect immediately. They call for the creation of a national oversight committee to review all proposals for research involving embryonic stem cells and establishment of a uniform ethical code for all such publicly funded research. The committee is to include experts in stem cell biology and therapeutics and ethics and law, as well as members of the public. The CIHR does not have a mandate to create a framework for private sector research. At present, Canada has no legislation governing either publicly or privately funded stem cell research. CMAJ 2002;166(8):1077

Opening up research ethics boards

Research ethics boards are charged with protecting the rights and welfare of research subjects participating in studies associated with their institution. A commentary calling for a centralized system to track decisions by research ethics boards cautions that they currently cannot share information even when reviewing the same research protocol because most of them are constrained from sharing confidential information about matters before them. The author recommends changes that will increase communication and coordination, and offer legal immunity for doing so. CMAJ 2002;166(10):1279-80

Placebo trials and tribulations

The most divisive debate within psychiatric research today involves the proper role of placebo controls in clinical trials that test the effectiveness of new drugs. Canada's Tri-Council Policy Statement carefully defines the conditions under which placebo controls may be used legitimately. It stipulates that "[t]he use of placebo controls in clinical trials is generally unacceptable when standard therapies or interventions are available for a particular patient population." The Declaration of Helsinki provides a similar prohibition. Unfortunately, at least in some cases, Canada's researchers, research institutions and government aren't abiding by these requirements. CMAJ 2002;166(5):603-4

GENETICS

Adults with genetic disorders

As our genome continues to unravel, scientists and clinicians are appreciating the important role of DNA in the development of many common diseases. Although most adult diseases are multifactorial, meaning that genetic factors combine with environmental ones to produce a phenotype, there are specific genetic conditions that manifest themselves in adulthood. One article lists reasons why one might suspect a genetic disorder in an adult and describes an approach to diagnosis, necessary investigations and potential treatments. CMAJ 2002;167(9):1021-9

A related article, Genetics 101 describes the technique that has given science its success with genetic sequencing. The polymerase chain reaction amplifies segments of DNA, sometimes a billion-fold, and has become integral to testing for parasitic, viral or bacterial DNA and diagnosing genetic diseases. CMAJ 2002;167(9):1032-3

Federal committee backs patenting of some life forms

The Canadian Biotechnology Advisory Committee has opted to support the patenting of life forms, such as seeds and plants, in the hope that this will advance biotechnology and other research in Canada. The committee, an arm's-length expert body funded by the federal government, is against granting patents on humans at any stage of development. It does support the patenting of higher life forms, subject to certain limits. It is making its recommendations before the Supreme Court of Canada rules on patent issues concerning Harvard University's "oncomouse," a case that has highlighted issues surrounding intellectual property rights. The oncomouse was genetically modified to develop cancer. It has already been patented in the US and its creators want a similar patent here. CMAJ 2002;167(8):912

Gene patents and the standard of care

The discovery of DNA and the sequencing that has followed have created one of the most fascinating and ethically ripe areas of science. For the first time, DNA testing allows patients and their physicians screening tools for inheritable illnesses. These advances, however, are being tempered by the conventional wisdom that to encourage development, it is necessary to patent innovative technologies. A DNA sequence patent gives the holder considerable power over how the genetic material can be used. For example, the patent holder may charge a premium for testing or offer it only at specific sites. The dilemmas facing health care systems are both ethical and financial. Are Canadian physicians obliged to advise their patients of possible gene testing only available in Europe? How is our system to support the cost of increasing for-profit screening?

Two commentaries address the controversy. One summarizes gene patenting and its societal cost (CMAJ 2002;167(3): 256-7).

The other commentary describes the potential effects of the controversy on Canadian medical practice. CMAJ 2002;167(3):259-62

A related commentary introduces the "very youngest science," molecular medicine, the origins of which may be traced back to the 19th century science of Darwin, Wallace and Mendel. CMAJ 2002;167(3):253-4

Genetic susceptibility of the fetus

The health of a developing fetus can be adversely affected by maternal medication but genetic susceptibility may also be a factor. Researchers describe the potential role of such genetic predisposition, with particular attention to cigarette smoking, alcohol use and antiepileptic drugs. They also provide a succinct summary of suitable genetic risk counselling. CMAJ 2002;167(3):265-73

Genetics 101: detecting mutations in human genes

Since the discovery of the double-stranded DNA in 1953, a fascinated public has watched its mystery slowly unravel. In addition to the insight offered into the marvellous intricacy of nature, major advances in medical diagnosis and therapeutics have been gained. Genetics is becoming established as a crucial element in the pathophysiology of many of our most difficult diseases, with mutations in a chromosome's delicate structure often being the cause. An expert describes how DNA encodes information, how mutations occur and how they are identified using both existing and new methods. CMAJ 2002;167(3):275-9

GERIATRIC MEDICINE

Decline in falls

From 25% to 35% of elderly people fall each year, making falls the leading cause of accidental death, morbidity and hospital admissions for those older than 65. Researchers from the University of British Columbia found encouraging results from a randomized controlled trial of an exercise program designed to reduce the number of falls involving women aged 65 to 75 who have osteoporosis. Women who participated in a community-based exercise program showed improvements in dynamic balance and strength, both of which are important determinants of risk for falls. The authors conclude that health authorities should consider paying for exercise programs for people with osteoporosis. The cost is relatively small — for a 20-week program involving 48 people it was $4800. CMAJ 2002;167(9):997-1004

Delirium research setback

Early systematic detection and multidisciplinary treatment of delirium in older patients who had been admitted to hospital offers no advantage over standard diagnosis and care, a new study indicates. Researchers compared 113 individuals in a control group receiving usual care with 114 who received early systematic detection and multidisciplinary care to determine if subjects in the latter group showed any improvement in cognitive status. The authors report no statistically significant difference between the two modes of care and suggest research efforts should focus on the prevention of delirium in elderly patients. CMAJ 2002;167(7):753-9

A related commentary states that, while the results of this study may be disappointing, health care professionals cannot give up on developing more effective ways to manage delirium. CMAJ 2002;167(7):763-4

Drug copayments in Quebec

In 1996 Quebec increased elderly patients' copayments for prescription drugs. At the time there was some concern that people's health would suffer because they would forgo drugs because of the added cost. But a study has determined that the increase has not affected the use of prescriptions for essential cardiac medications among elderly patients who have had a heart attack, regardless of sex or socioeconomic status. The authors conclude that the increase had no "apparent adverse health consequences related to acute myocardial infarction," but also note that, since the study focused on essential cardiac medications, "patients in this situation might have felt compelled to fill any prescription given, whatever the cost." CMAJ 2002;167(3):246-52

Improving the management of urinary incontinence

The prevalence of urinary incontinence in people aged 65 years or older living in the community ranges from 8% to 30%, but those affected by it are often too embarrassed or ashamed to seek help. Researchers randomly assigned 421 patients experiencing urinary incontinence at least once a week to either a control group or to a group that participated in a lifestyle and behavioural intervention session every 4 weeks. The sessions were led by a nurse continence adviser, in collaboration with a physician. Data were analyzed for 188 patients in each group, with the primary outcomes measured being the number of incontinence episodes per 24-hour period and the use of incontinence pads.

The authors report that mean decrease in incontinence events per 24 hours was greater in the intervention group than in the control group (1.2 versus 0.2). The mean decline in the use of incontinence pads per 24 hours was also greater in the intervention group (0.9 versus 0.1). The authors conclude that nurse continence advisers can play an important role in the management of patients with urinary incontinence. CMAJ 2002;166(10):1267-73

Hip fracture care

Elderly people with hip fractures are at increased risk of death or impaired function and ambulation. A new randomized controlled trial concludes that post-operative interdisciplinary care in hospital doesn't appear to improve long-term outcomes for these patients. A follow-up of study participants at 3 months and 6 months determined the number of patients who were living with no decline in ambulation or ability to transfer in and out of a chair or bed and no decline in residential status. At 6 months, 56 patients (39.7%) in the interdisciplinary care group and 47 (34.1%) in the usual care group were alive with no decline in ambulation, transfers or residential status. The primary outcome measure did not differ significantly between the 2 groups at 3 or 6 months, nor did the mean length of stay in an institution (including hospital, inpatient rehabilitation and nursing home). CMAJ 2002;167(1):25-32

The prevalence of osteoporosis

Osteoporosis is increasing, and so is the concern surrounding it, because osteoporosis is a major cause of fractures. Conservative estimates peg a 50-year-old Caucasian woman's remaining lifetime risk at 40% for hip, vertebra or wrist fractures. While these numbers, buttressed by our aging population, are sobering, it is important to understand that osteoporotic fractures are preventable. In a special 34-page CMAJ supplement, members of the Scientific Advisory Council of the Osteoporosis Society of Canada presented updated guidelines on risk factors, diagnosis, nutrition, physical activity, drug therapies and alternative/complementary therapies as they relate to osteoporosis. To do so the authors reviewed 89 804 abstracts and 6941 full articles, resulting in 45 evidence-based recommendations for Canadian physicians to follow. CMAJ 2002;167(10):supplement

Reducing the risk of osteoporotic fractures

Age-related bone loss is the main cause of hip and vertebral fractures in elderly people. A number of drugs have been used to slow down the progress of osteoporosis and to reduce the risk of fractures. The bisphosphonates are a new class of compounds that act by selectively inhibiting osteoclast function, and thus bone resorption, during the remodelling cycle of bone turnover. Randomized controlled trials have demonstrated gains in bone mineral density of 4.5%-8.3% at the lumbar spine and 1.6%-3.8% at the femoral neck for patients treated for 3-4 years with bisphosphonates. Researchers evaluated the evidence to date that these increments in bone mineral density during bisphosphonate therapy translate into a reduction in observed fractures. CMAJ 2002;166(11):1426-30

HEALTH POLICY & POLITICS

Auditor General slams Health Canada

Health Canada's Population and Public Health Branch uses no formal process for making "rational, evidence-based decisions" on program priorities and often breaks its own rules in granting funds, Canada's Auditor General says. In her report on federal spending, Sheila Fraser said the branch has few mechanisms for determining whether programs work, let alone improve the health of Canadians. CMAJ 2002;166(3):365

BC slashes health spending

British Columbia is delisting some covered medical services, cutting its Pharmacare plan and slashing the administrative budget of its Ministry of Health in a bid to bring health spending under control. The system is not sustainable, Health Minister Colin Hansen told CMAJ early in 2002. The ministry aims to maintain health care expenditures at $9.5 billion annually for the next 3 years, and this will mean annual cuts will be needed to negate the effects of inflation. But the province is already over budget. In 2001, BC spent $9.6 billion on health care, which accounted for 40% of total spending. CMAJ 2002;166(4):492

In April, the BC government pledged to overhaul its health care system "to fulfill a New Era promise to provide high quality, public health care services." However, for many the new era is starting to look a lot like the old one, with escalating labour disputes and disagreements over the provision and funding of care. The restructuring, which is supposed to save $567 million, includes $74 million over 4 years to bolster primary care by strengthening family practices and providing "teams of care" to reduce pressure on the acute care system. CMAJ 2002;166(12):1582

"Completely ridiculous" demands ruining medicare

A spirited attack on a society that places many unnecessary demands on Canada's health care system was the focus of a lecture in May at the annual meeting of the Canadian Health Economics Research Association. Dr. Charles Wright contended that the demand side of the health care equation has been ignored in recent reviews of medicare because all attention has been focused on the supply of medical and health services. Wright, a professor of health care and epidemiology at UBC, said Justice Emmett Hall could not have foreseen how the scope of and demand for services would grow as he helped create Canada's medicare system in the 1960s. He said current popular thinking that medicare can publicly fund all medical services that all people might want and demand is "completely ridiculous." CMAJ 2002;166(13):1707

Concern over rights of Quebec MDs

Few patients have had as much impact on a health care system as Claude Dufresne. Dufresne, 51, died June 20 while en route to hospital in Trois- Rivières, Que., 30 minutes from his home in Shawinigan-Sud. Dufresne, who had suffered his second myocardial infarction in 6 years, lived 3 blocks from his town's emergency department, but it had closed at midnight due to a physician shortage. Thirty-five days after his death, the Quebec legislature responded by passing Bill 114, which enables regional health boards to conscript GPs to work in the province's understaffed ERs. Those who refuse face fines of up to $5000. Dr. Renald Dutil, president of the Fédération des médecins omnipraticiens du Québec, says the law goes far beyond ensuring 24-hour emergency services. "It puts doctors under the power of the Essential Services Council, subject to the Quebec Labour Code," he says, and this means that the government no longer considers doctors autonomous professionals. "And we just can't accept that." CMAJ 2002;167(5):530

As Quebec's physicians plan a court challenge of the controversial legislation that either forces them to staff emergency departments or face $5000-a-day fines, they're drawing lots of support from doctors across the country. Feelings were running so strongly during the CMA's 135th annual meeting that delegates held an emergency debate Aug. 21 and passed 7 motions that called the Parti Québécois actions an attack on physician autonomy and supported Quebec MDs' fight against them. Running through the meeting was a strong current that the actions might have a domino effect. Many physicians are convinced that Bill 114 violates Canada's Charter of Rights and Freedoms. CMAJ 2002;167(6):681

For-profit or not?

Researchers provided fodder for the discussions about private for-profit health care delivery in Canada with a systematic review and meta-analysis of studies comparing mortality rates in private for-profit and private not-for-profit hospitals in the United States. They report that in the studies of adult populations, with adjustment for potential confounders, private for-profit hospitals were associated with an increased risk of death (relative risk [RR] 1.020, 95% confidence interval [CI] 1.003-1.038). One perinatal study with adjustment for potential confounders also showed an increased risk of death in private for-profit hospitals (RR 1.095, 95% CI 1.050-1.141). CMAJ 2002;166(11):1399-1406

A commentary assesses the actual price of for-profit hospitals in the Canadian context. CMAJ 2002;166(11):1418-9

Another commentary points out flaws in the research, but finds its conclusions are still pertinent. CMAJ 2002;166(11): 1416-7

Health spending rises

Provincial spending on health care increased for the fourth straight year in 2000, after 5 years of low growth or declining expenditures. Preliminary provincial and territorial health spending data released by the Canadian Institute for Health Information show that the amount spent on health care reached $59 billion in 1999, accounting for just over 35% of all provincial government spending. That is expected to have climbed to 37% during 2001. CMAJ 2002:166(1):82

Kirby report recommends income-based health premium

Liberal Senator Michael Kirby insists that the report prepared by his 11-member committee, entitled The Health of Canadians — The Federal Role, contains the prescriptions needed to stave off the development of a parallel, private system. Two-tier medicine is "the inevitable consequence of failing to reform the system now," he said. The Oct. 25 report concludes that public funding is the most efficient way to fund health care, but more of the service delivery could be done privately. To that end, the committee urged the adoption of a new health premium to fund new measures, such as a national pharmacare program. It also urged the federal government to earmark a revenue source — possibly half of its GST revenue — to ensure the long-term sustainability of federal cash transfers to the provinces for health care. The health premium would be levied according to existing tax brackets, starting at 50 cents per day for those with taxable incomes under $31 000 and rising to $4 per day for those earning more than $103 000. Kirby says the measures would generate $5 billion a year to expand and restructure the system. CMAJ 2002;167(11):1279

Low-volume sites to close

More than 130 000 Ottawans signed a petition protesting the closure of the local pediatric cardiac surgery unit, but consolidation of low-volume, highly specialized surgery may be inevitable. In January 2002 the premiers of all provinces except Quebec approved the move toward consolidation. The premiers announced that consolidated sites would "lead to better care for patients and more efficient use of health care dollars" Eventually, says Dr. Hugh O'Brodovich, chief of staff at Toronto's Hospital for Sick Children, there will only be "2 or 3 centres in Canada doing [pediatric cardiac surgery]." There are now 8. CMAJ 2002;167(2):177

Medical savings accounts: Who pays?

One of the more interesting — and hotly debated — ideas for health care reform ideas are Medical Savings Accounts (MSAs). Under such plans governments would contribute funds into individuals' MSAs that could then be used to purchase health services. Unspent funds would accumulate and could eventually be spent on a broader range of goods and services. MSAs have the potential to give people greater control over access to health care services and incentives to seek the most competitively priced services.

But researchers found that MSAs would not lead to savings in health care spending. They assessed costs incurred by individual Manitoba residents for all physician visits and admissions to hospital between 1997 and 1999 and used the data to calculate an average-age expenditure per person per of $730 per year for the 3 years. The authors conclude that if the $730 threshold was used as the MSA entitlement in the province, total government spending on health care would increase by $505 million. CMAJ 2002;167(2):143-7

In a review of the scant literature on the use of MSAs in publicly financed health care systems, another expert concludes that current knowledge of their use is too limited to recommend them for the Canadian health care system. CMAJ 2002;167(2):159-62

However, David Gratzer, a staunch proponent of MSAs, suggests the time has come to at least experiment with MSAs in order to learn more. CMAJ 2002;167(2):151-2

New minister of health

Within days of being made federal health minister in January, Anne McLellan was off and running. On CTV's Question Period, the new minister broke a Liberal taboo by raising the possibility that companies could build and run private hospitals that might be allowed to operate within the Canadian health care system. In early February she announced that she wants Ottawa and the provinces to develop quickly a dispute-resolution procedure to settle disagreements about the Canada Health Act (CHA). CMAJ 2002;166(5):639

Primary care reform slow to attract MDs

The Ontario government hopes to have 80% of family physicians practising in new family health networks (FHNs) by 2004, but it appears unlikely that hope will become reality. Only a handful of the province's 6300 FPs have signed on since the $463-million program was launched in May, and even the chair of the province's Family Health Network, Dr. Ruth Wilson, agrees that 80% is "an ambitious goal." Physicians who join an FHN are encouraged to work in multidisciplinary teams and provide 24-hour-a-day service to rostered patients through a combination of extended evening and weekend hours, a shared on-call service and an after-hours telephone advisory service. They are also encouraged to provide a broad range of medical services, including obstetrical and palliative care. CMAJ 2002;167(10):1159

Research spending to hit $1 billion

Health Minister Anne McLellan and Dr. Alan Bernstein both foresee a $500-million raise for the Canadian Institutes of Health Research (CIHR). But the timing of the increase is another matter. In June, McLellan said Ottawa will increase CIHR funding to $1 billion "in the near future." Bernstein, the CIHR president, says the "near future" is 3 years and that he is only echoing McLellan and her predecessor, Allan Rock, when he calls for funding growth to $1 billion by 2005. CIHR had a $560-million budget in 2002. Its first budget, in 2000, was $365 million. CIHR, which replaced the Medical Research Council of Canada in June 2000, is the country's premier federal agency for health research. CMAJ 2002;167(2):179

Romanow's cross-country tour

When Roy Romanow opened his public hearings on medicare in Regina in March, he said he hoped to rekindle the same passion found in Saskatchewan 4 decades earlier when the province "launched a huge debate — very passionate, sometimes too passionate — about values and ideals about the way medicare should be organized." But can Romanow overcome the suffocating cynicism about Ottawa's motives in launching his one-man commission on the Future of Health Care in Canada? The mood was promptly articulated by one of the first presenters in Regina, the Council of Canadians' Maude Barlow. She said the commission's 18-city tour is nothing but a ruse to distract Canadians while provinces such as Alberta, British Columbia and Ontario push ahead on the privatization front. Michael Decter, Ontario's former deputy minister of health, was only marginally less skeptical when he spoke with CMAJ. "There are no new ideas out there, and there are so many vested interests," he said.

In February, Romanow's interim report outlined the 4 basic options for reform: additional public money; the introduction of user fees or copayments; private sector participation; and reforms to improve efficiency, but without any new money. If he is successful in generating public discussion, by the end of the public hearings on May 16 he should have an idea which option Canadians favour. CMAJ 2002;166(9):1199

Romanow hears from CMA

The CMA released 30 detailed recommendations on the medicare system in an attempt to pry open what it calls the "black box of bureaucracy" surrounding health care. "Canadians have the right to know exactly what to expect when they need health care, so at the heart of our prescription package is the Canadian Health Charter," President Henry Haddad said in June as he released the CMA's proposals for reform to Roy Romanow's Commission on the Future of Health Care in Canada. "A health charter will spell out everyone's rights and responsibilities in providing and receiving health care — patients, health providers and even government." CMAJ 2002;167(2):178

Romanow hears it all in Ottawa

From an irate teenager's cry that "corporate health care sucks" to squabbles between consumer groups and the pharmaceutical industry, usually-staid Ottawa was uncharacteristically impassioned during Roy Romanow's eighth public consultation on the future of medicare in April. Despite the crazy-quilt nature of the consortium of 29 speakers and groups that appeared — feminists, coalitions, unions, nurses, physicians, an industry association, First Nations — all delivered the same basic message to Romanow's one-man commission: We don't want privatization. CMAJ 2002;166(10):1323

Romanow listens to conflicting messages

If Roy Romanow was listening when Canadians spoke to him in the spring of 2002, he learned that privatization is the saviour of medicare and its nemesis. That the system must expand and that it must contract. That for-profit care must be fought tooth and nail, and that it must be embraced. Essentially, the head of Canada's one-man commission received so many opposing messages during his 18-city tour that Canadians have to wonder what compromise solution he can possibly concoct by the time his final report is released in November. Will he call for governments to spend more, or to produce a leaner, meaner system? By the end of his tour, the only sure thing was that he won't be able to please everyone. CMAJ 2002;166(13):1703

Romanow promises speedy improvements

Roy Romanow has promised Canada's doctors that clarity and speedy action will be the watchwords for recommendations emerging from his much-anticipated report on the future of medicare. Speaking at the CMA's 135th annual meeting Aug. 20, the former Saskatchewan premier said Canadians could start seeing improvements in medicare within "a few short months" of his report's November release, although some improvements will definitely take longer. And governments will reject his report at their peril, he warned. "If the report ... resonates with [Canadians'] values and with how they think the system can be repaired [and the government then rejects it], I think that is a prescription for political suicide." CMAJ 2002;167(6):681

Roy Romanow's report, released November 28, reflect his steadfast stance in his defence of Canada's publicly funded health care system. The report's 47 recommendations set total annual federal funding for health at $15.32 billion by 2005/06. The current level is $8.82 billion. It calls for a "federal cash floor" of 25% of health services insured under the Canada Health Act, and an additional $6.5 billion in federal health spending in 2005/06 (once 25% floor is achieved). Other features include a rural and remote access fund ($1.5 billion over 2 years) to improve timely access to care in rural and remote areas; a diagnostic services fund ($1.5 billion over 2 years) to lower wait times for diagnostic services; a primary health care transfer fund ($1.5 billion over 2 years); a ome care transfer fund ($2 billion over 2 years) to help develop national home care strategy; catastrophic drug transfer ($1 billion beginning fiscal year 2004/05) to protect against expensive drug therapies; a new Canadian Health Covenant to detail "responsibilities and entitlements"of governments, providers and patients in the system; and, a new Health Council of Canada to set benchmarks for health care and measure performance.

The debate on health care reform in Canada

In May, CMAJ launched a series of essays on medicare, as Canadians continue to follow the deliberations of the Commission on the Future of Health Care in Canada headed by Roy Romanow. In the first essay, Steven Lewis argues that health care federalism is where durable solutions to medicare's woes lie. CMAJ 2002;166(11):1141-2

TV host, David Suzuki, Chair of The David Suzuki Foundation and Professor Emeritus of Sustainable Development Research at the University of British Columbia, says that "if the ultimate goal of a health care system is to keep people well rather than simply to treat them when they are sick, then we must broaden the health care debate in Canada and reconsider the push toward for-profit health services." CMAJ 2002;166(13):1678-9

INFECTIOUS DISEASES

AIDS and indifference

The most recent AIDS statistics are so overwhelming they are almost difficult to believe. Many countries in Africa are teetering on the brink of disaster as a growing proportion of their workforce is infected with HIV. A researcher who attended the July 2002 international AIDS conference in Barcelona reports on the powerful implications of its theme, "knowledge and commitment for action," and the extent to which Canada must expand its role or risk failing the people who need our help. CMAJ 2002;167(5):483-4

The winning entry for the 2001 CMAJ Essay Prize, "AIDS, Africa and indifference," articulates the difficulty one physician has in truly comprehending the plight of people thousands of miles away. The author describes the helplessness one might feel as a committed, compassionate physician in Canada, "believing that things ought to be otherwise, and chastising [oneself] for doing so little." CMAJ 2002;167(5):485-7

An anniversary to forget

Twenty years ago this month, on Mar. 27, 1982, Canadian physicians received the country's first official report of a disease that was starting to cause concern within the country's gay community. That 700-word case report on AIDS, "Pneumocystis carinii pneumonia in a homosexual male — Ontario," was the first of hundreds. Since then, more than 18 000 Canadians have received the same diagnosis as that first patient, a 43-year-old man from Windsor, Ont. CMAJ talks to the physician who filed that first report and to 2 doctors whose professional careers were transformed by AIDS. The journal also reprints the surprisingly prescient abstract from the first Canadian review article on AIDS, which it published in 1983. CMAJ 2002;166(6):789

Fighting the biggest killers

One of the key issues in the struggle against global illnesses is that the most deadly illnesses (tuberculosis, malaria and HIV/AIDS) have defined themselves largely along economic and social boundaries. As such, people who need medicines most are the least likely to be able to afford them. James Orbinski, past president of Médecins Sans Frontières, discusses the missed opportunity that the G8 meeting in Kananaskis had to endorse strategies that support equitable access to medicines and to offer a meaningful contribution to the fight against our world's biggest killers. CMAJ 2002;167(5):481-2

HIV infection among female injection drug users

Researchers warn that HIV incidence is on the rise among female injection drug users in Vancouver and that the increase is being driven by factors different from those found in males. In 1996, these researchers recruited 939 participants (624 men and 315 women) who were HIV negative at enrolment and who completed follow-up study visits and serology tests up to March 2001. Over the period, seroconversion occurred in 64 men and 46 women. The authors found that among the female participants, independent predictors of seroconversion were: injecting cocaine at least once a day, needing help to inject, having unsafe sex and having an HIV-positive partner. Among male participants, the independent predictors were: injecting cocaine more than once a day, being Aboriginal and borrowing needles. The authors say the findings point to the urgent need for sex-specific prevention initiatives. CMAJ 2002;166(7):894-9

A related commentary discusses the public health and social policy implications of the different sets of predictors. The author warns that the study also delivers disturbing news about Canada's Aboriginal population: HIV infection rates for both men and women were about twice as high as in the non-Aboriginal population. CMAJ 2002;166(7):908-9

Influenza vaccination adverse event

During the 2000-01 flu season, a new adverse event was associated with vaccination: oculorespiratory syndrome (ORS). Ninety-six percent of the 960 ORS cases were linked to one manufacturer's brand of vaccine, and precautions were taken for the 2001-02 season to avoid its use in the revaccination of previously affected individuals. Investigators surveyed 609 people who reported adverse events in the 2000-01 season to better understand the risk of recurrence of ORS. They found that in 2001-02, 122 of those whose adverse reaction was ORS were revaccinated and showed only a 5% recurrence rate of ORS, with most reactions being milder than they had been before. CMAJ 2002;167(7):853-8

Injection facilities needed

A nationwide project to provide safe injection facilities is needed to help protect the 125 000 Canadians who inject illegal drugs, the Canadian HIV/AIDS Legal Network says. "Canada is in the midst of a public health crisis concerning HIV/AIDS, hepatitis C, and injection drug use," network Executive Director Ralf Jürgens said during the April release of a 70-page report, Establishing Safe Injection Facilities in Canada: Legal and Ethical Issues. It says overdoses involving illicit drugs have been the leading cause of death among British Columbia residents aged 30-49 for the last 5 years. In 1999, 34% of the estimated 4190 new cases of HIV infection in Canada involved injection drug users; more than 60% of the more than 5000 new cases of hepatitis C infection reported in Canada each year are related to injection drug use. CMAJ 2002;166(11):1455

Lack of antiretroviral therapy

Of the 40 million people currently living with HIV/AIDS, 36 million do not have access to the antiretroviral (ARV) therapy that would prolong their lives. According to the UN, 96% of people infected with HIV live in developing countries where they do not have access to treatment. Humanitarian activist organizations argue that the HIV/AIDS pandemic is fuelled in part by industrialized countries' failure to mobilize promised resources for prevention, treatment and advocacy. HIV/AIDS is currently causing an estimated 10 000 deaths a day. CMAJ 2002;167(5):534

Leaving hospital against medical advice

In an attempt to understand why patients leave hospital against medical advice, researchers reviewed all first admission records for HIV/AIDS patients admitted to St. Paul's Hospital in Vancouver between Apr. 1, 1997, and Mar. 1, 1999. Of the 981 patients, 125 (13%) left hospital against medical advice. The authors found that departure on the day that welfare cheques were issued and a history of injection drug use were significant predictors of this action. Most troubling, however, is the finding that patients leaving against medical advice were more likely to be readmitted with the same diagnosis. The authors suggest that a redesign of welfare policies to allow full payment to hospitalized recipients would help reduce these numbers. CMAJ 2002;167(6):633-7

A related commentary suggests that brief interventions addressing underlying conditions such as alcohol or drug dependence and direct communication of the reasons for continuing a hospital stay may prevent some discharges against medical advice. CMAJ 2002;167(6):647-8

Preventing mother-to-child HIV transmission

Although all pregnant women in Canada are supposed to be offered voluntary HIV testing to allow treatment and possible prevention of transmission to the baby, cases are still missed. Researchers retrospectively reviewed the hospital charts of all infants diagnosed with perinatally acquired HIV infection between August 1999 and July 2001 and found 6 cases involving HIV-positive infants whose mothers did not know their own HIV status before or during their pregnancy. The authors suggest that the incomplete application of guidelines for universal HIV prenatal counselling and voluntary testing are the reasons for continued perinatal transmission. They recommend universal HIV testing and counselling for pregnant women unless the woman specifically objects. CMAJ 2002;166(7):904-5

A related commentary discusses 5 critical steps needed to prevent perinatal HIV transmission. CMAJ 2002;166(7):909-10"

Rapid HIV test pulled

Rapid point-of-care HIV test kits promise a fast, sensitive screen for HIV antibodies. However, the British Columbia Centre for Disease Control has identified problems with the sensitivity of these test kits. Since April 2002, when a Health Canada advisory was issued on the subject as a result of the BC investigations, additional performance problems have been discovered. CMAJ 2002;167(2):119

In a related article, the director of an STD clinic in Toronto says that only 400 of 1900 people have returned for retesting after taking a rapid HIV test that produced false-negative results. CMAJ 2002;167(2):180

Smallpox anniversary

On Oct. 26, 1977, the world's last case of naturally acquired smallpox was reported in Somalia. Three years later, the World Health Organization declared the world free of naturally occurring smallpox. Eradication of the disease, a campaign that began in 1966, was considered an unprecedented accomplishment. In Canada, an average of 2263 cases of smallpox were reported yearly between 1924 and 1929, and the last endemic cases occurred in 1946. The last case of smallpox imported to Canada was reported in 1962. CMAJ 2002;166(11):1278

TB's spread

Tuberculosis is a leading cause of death and illness in the world. Advances in molecular epidemiology have improved our understanding of how Mycobacterium tuberculosis is spread. Two groups of investigators describe how they used DNA fingerprinting to determine whether patients with newly diagnosed tuberculosis had isolates belonging to genetically similar clusters of recent infection or had unique isolates representing reactivated disease. They gathered epidemiologic data to delineate groups at risk of new infection. The Vancouver investigators found that Canadian-born Aboriginals and patients with a history of injection drug use are at high risk. CMAJ 2002;167(4):349-52

In related research, Montreal investigators have identified Haitian immigrants as particularly vulnerable. CMAJ 2002;167(4):353-4

A related commentary discusses the dynamics of transmission among foreign-born people. The author reminds the medical community that new Canadians should be a target of infection control strategies. CMAJ 2002;167(4):355-6

West Nile virus heads west

As of mid-August, the West Nile virus had appeared in at least 4 provinces and was likely to continue spreading, an expert at the Canadian Science Centre for Human and Animal Health said. Health Canada had reported no confirmed human cases in Canada, but nearly 200 birds tested positive for the virus in Quebec, Ontario, Manitoba and Saskatchewan. CMAJ 2002;167(6):680

INFORMATICS

Ottawa investigates "suspicious" Web sites

Twenty-five Canadian Web sites are being investigated by Canada's Competition Bureau following an international sweep that uncovered 1041 "suspicious" health-related sites worldwide. About 50 were in Canada, and half of them are "potentially problematic," according to officials at the bureau's National Internet Surveillance Project. Corporate offenders can face fines for a first offence under the Competition Act. Most of the 25 Canadian sites being investigated are selling longevity and weight-loss products. Canada's sweep is part of a global effort by 29 countries, which is led by the International Marketing Supervision Network. The network helps prevent and redress deceptive marketing practices. CMAJ 2002;166(11):1454

Telehealth spreading

Telehealth, initiated about 6 years ago in Canada, is designed to provide an information buffer between patients and the medical services they seek. By the end of last year, 80% of Canadians had access to telephone triage. CMAJ 2002;166(1):80

INTERNATIONAL MEDICINE

AIDS activist released from Chinese prison

After spending 26 days in a detention centre, a prominent Chinese AIDS activist was released when he confessed to breaking the law and leaking state secrets. Dr. Wan Yanhai, an outspoken physician and critic of China's slow response to HIV/AIDS, had publicized a growing epidemic in Henan province, where many rural villagers were infected because of faulty blood-collection practices at government-sponsored clinics. Western media had previously reported how the blood was collected and sold to manufacture various pharmaceutical products. Early in August, Wan anonymously received a secret government report documenting 170 deaths, which he forwarded on an email list. On Aug. 24 Wan was reported missing, and North American human-rights and AIDS groups began lobbying for his release. CMAJ 2002;167(9):1044

Arsenic poisoning in Bangladesh

Up to half the residents of Bangladesh — some 77 million people — are being exposed to high levels of naturally occurring arsenic in what the World Health Organization calls the "largest mass poisoning of a population in history." The problem reaches back 30 years, when 9 million narrow, shallow tube wells were dug throughout the country to prevent water-borne diseases caused by contaminated surface water. In 1993 the well water was discovered to contain dangerously high quantities of arsenic from geologic sources. The International Agency for Research on Cancer considers arsenic a human carcinogen. Arsenicosis can cause skin cancer and cancers of the bladder, kidney and lung, as well as diseases of the blood vessels and legs and feet, hypertension and reproductive disorders. CMAJ 2002;166(12):1578

Encouraging residents of Bangladesh to switch to safe wells could save millions of lives, a new study says. Researchers tested 4997 of wells in the Araihazar district (population 55 000) and found that 48% of them were safe. Although only half of these residents had access to safe water from their own well, 88% lived within 100 m of a safe one, and 95% within 200 m. "Well-switching should be more systematically encouraged," concluded the US researchers. CMAJ 2002;167(9):1048"

Cheap vaccine needed for meningitis epidemic

With an epidemic of a rare strain of meningitis threatening to infect up to 4 million Africans by January 2003, the World Health Organization (WHO) made an urgent plea for an affordable vaccine. The cost of US$5 per dose is prohibitive for poor African countries like Burkina Faso. CMAJ 2002;167(10):1157

Famine in Southern Africa

An estimated 16 million people in southern Africa do not have enough food to last the 6 months until next year's harvest. October data derived from an emergency food assessment conducted by a United Nations special envoy indicated that 1.6 million more people are at risk than was predicted in May. "The new figures confirm [that] the humanitarian crisis is devastatingly real [and] worsening faster than originally projected," said UN spokesperson James Morris. "This crisis must be an absolute top priority for the international community." CMAJ 2002;167(11):1277

Gender segregation in Iran

The segregation of the sexes in Iran means there are more opportunities for women to pursue medical careers. In the early 1980s, Ayatollah Khomeini, the supreme leader (Imam) of Iran, said the physical examination of female patients by male gynecologists violated religious rules. Thereafter no male gynecologists were trained and female-only hospitals were set up. To ensure that there are enough female physicians to treat the country's 35 million women and girls, Iran will be training thousands of new female doctors over the next 2 decades. Ten years ago only 12.5% of Iranian medical students were women. Today, one-third of the 22 326 medical students are women. CMAJ 2002;166(5):645

India cracks down on sex-determination tests

Indian health officials have begun a well-publicized campaign to register all medical centres in the country that offer prenatal sex-determination services through ultrasonography, amniocentesis and other techniques. The move follows a directive from the Supreme Court of India to submit a report on the question. A 1994 law prohibits Indian doctors from carrying out sex-determination tests if female fetuses will be aborted as a result. However, centuries of tradition demand that every couple produce at least one male child, and even today most couples would go to any extent to do that. CMAJ 2002;166(6):800

India's innovative cheap drug program

A program that encourages physicians to prescribe cheaper drugs has led to a 40% reduction in drug prices and a significant increase in the availability of essential drugs. The World Health Organization hails the "very successful" Delhi Essential Drugs Program as an example for the developing world to pursue. Established in 1996, the program tackled constant shortages and high prices of essential medicine in state hospitals, which are used by about 35% of Delhi residents. Under the program, doctors are advised to prescribe only medicines on an essential drugs list, which includes generic drugs that can be produced and purchased cheaply in bulk. CMAJ 2002;167(4):386

Invest in international health

Increased spending of $66 billion per year to improve the health status of developing nations will provide a sixfold return on the investment, a group of leading economists and public health experts says. In a report prepared for the World Health Organization (WHO), the Commission on Macroeconomics and Health concludes that the increased investment — half to come from developed countries like Canada and the rest from "reprioritizing" the budgets of underdeveloped nations — would provide the large returns because healthier people would live longer and be more productive. Under the plan, "official development assistance" from countries like Canada would increase from its current level of $6 billion per year to $27 billion by 2007. The commission concludes that the additional spending would save about 8 million lives a year. CMAJ 2002;166(3):361

Northern Ireland's heavy prescribing

Residents of Northern Ireland take 75% more tranquillizers and sedatives and 37% more antidepressants than other Britons, a study prepared for a British mental health charity indicates. Author Raman Kapur says the region's overall mental health needs are 25% greater than in the rest of the country. He blames the disparity on the Troubles — the decades of sectarian violence. Despite ongoing peace talks, he says a war psychology has persisted and people remain reluctant to talk about their fears. CMAJ 2002;167(6):682

South African brain drain costing $5 billion

The flight of South Africa's medical professionals seems unending, despite the country's pleas for rich countries to stop poaching its doctors and nurses. This year the number of South Africa-trained physicians practising in Canada has risen by 174, to 1738. Many more have left for the United Kingdom, Australia, New Zealand and the US. The exodus, which is largely driven by a burgeoning crime rate and problems within the health care system, has also been encouraged by an economic downturn. In 2001 the rand plummeted by 30% against the US dollar before rebounding somewhat this year.

The South African Health Review reports that the public sector's doctor-patient ratio declined from 21.9 physicians per 100 000 people in 2000 to 19.8 per 100 000 in 2001. The ratio for nurses also shrank, from 120.3 per 100 000 in 2000 to 111.9 per 100 000 last year. An estimated 20 000 professionals flee Africa annually, a brain drain that has cost more than $5 billion in "lost human capital" since 1997. CMAJ 2002;167(7):793

UK boosts health spending

Britain is set to boost spending on its National Health Service (NHS) by 40 billion pounds over the next 5 years, a 43% increase that will be funded largely by tax increases. The announcement in May followed a series of scandals involving botched operations, overcrowded emergency wards and patients who died while awaiting treatment. The increased funding will cover the hiring of 7500 consultant specialists, and at least 2000 GPs, 20 000 nurses and 6500 therapists by 2004. Health authorities also plan to build 40 hospitals and 500 primary care centres. New targets for the NHS include reducing mortality rates for heart disease by 40% and for cancer by 20% in patients under age 75. CMAJ 2002:166(12):1579

US health spending soars

Fuelled by surging prescription drug and hospital costs, health care spending in the US in 2000 soared by 6.9%, to more than US$1.3 trillion. It is the biggest single-year increase in almost a decade. According to a report prepared by the US Center for Medicare and Medicaid Services, the resurgent costs (increases had been relatively small since 1993) were mainly attributable to a 17.3% increase in prescription drug spending. CMAJ 2002;166(6):791

UN special session on children

Representatives from around the world met in New York May 8-10, 2002, during the United Nations General Assembly Special Session on Children in an attempt to set new goals for realizing the rights of all children and adolescents. Before the meeting experts warned that a conservative social agenda being led by the administration of US President George Bush is attempting to "roll back" earlier agreements on the rights of adolescents to sexual and reproductive health information, education and services. CMAJ 2002;166(9):1155-7

A related editorial warns that "any attempt by the US and others to impose their conservative political agenda on the outcome document of the UN Special Session on Children this month is not only unrealistic, but reprehensible." CMAJ 2002;166(9):1125

In April, Canada's representative to the May UN General Assembly Special Session on Children cautioned Canadians not to expect too much from it. Given shifts in spending priorities and attitudes after the Sept. 11 attacks on the US, people have to be realistic about what can actually be achieved to improve children's health, says Senator Landon Pearson. The goals set during a similar special session in 1990 never were met. Each year 3 million children die due to environmental hazards and another 11 million die year from preventable problems such as pneumonia, dehydration and measles. In addition, one-third of children are malnourished or undernourished, a problem that contributes to 60% of all childhood deaths. CMAJ 2002;166(9):1198

World Health Assembly meets

Dr. Gro Harlem Brundtland, director general of the World Health Organization (WHO) came under fire from some of the representatives of 192 countries at the 55th World Health Assembly for insisting that WHO projects must be open for cosponsorship. Critics took aim at a new WHO-sponsored partnership, the Global Alliance for Improved Nutrition (GAIN), which will try to counter global malnutrition by getting companies to bring food to impoverished nations. On the one hand, critics say, WHO is promoting tobacco-free initiatives, while on the other hand it is allowing into GAIN partners that are linked to tobacco (Kraft, a GAIN member, is owned by tobacco giant Philip Morris). CMAJ 2002;167(7):792

WHO formulary for essential drugs

The World Health Organization (WHO) has marked the 25th anniversary of the publication of its Essential Drugs list by creating the world's first authoritative model formulary. The WHO Model Formulary presents information on the use, dosage, adverse effects, contraindications and warnings for the 325 basic "essential" medicines that WHO believes every country should make available to its citizens. It also crams important information on prescribing and rational drug use into a small blue book that fits easily into a pocket. CMAJ 2002;167(11):1278

JOURNALOGY

CMAJ appoints first ombudsman

Dr. John Dossetor is CMAJ's ethicist and ombudsman, the first appointments of their type for a Canadian scientific publication. In his role as ombudsman, Dossetor will investigate unresolved complaints about the journal's editorial process — for example, a failure to follow the procedures outlined in its information for authors or prescribed by the International Committee of Medical Journal Editors; inappropriate editing; delays; and discourtesy. In his role as the journal's ethicist he will advise CMAJ editorial staff on the questions of conduct they encounter from time to time. CMAJ 2002;166(10):1281-2

Ethical behaviour committee

Editors from health science journals across Canada are forming an association to promote ethical behaviour in research, peer review and editing. Editors from 63 peer-reviewed journals have agreed to form an independent organization to promote ethical behaviour in research and publishing and to develop educational resources for editors, peer reviewers and others. The organization will deal with issues of ethical and scientific misconduct, such as plagiarism and falsified data. CMAJ Editor John Hoey says scientific misconduct is likely under-reported here. Countries with monitoring organizations report 1 or 2 incidents per million population, which means there are probably 30 to 60 cases per year in Canada. CMAJ 2002;166(2):230

Ethics in the UK

UK scientists and researchers want a new body to monitor research and ensure that fiddling with facts doesn't undermine science's reputation. Almost 140 cases of possible breaches in publication ethics have been submitted to the UK Committee on Publication Ethics (COPE) in the past 3 years. The physicians, editors, researchers and others who comprise COPE want a national panel for research integrity to consider such breaches under a new national code of conduct. Breaches of the code would result in disciplinary action and the withdrawal of research funding. The panel would answer to a House of Commons committee. CMAJ 2002;166(4):490

"Fast-tracked" publication

A number of biomedical journals decide that certain articles should be accelerated through the review process and published early in order to rapidly disseminate especially important research or public health findings. To assess whether fast-tracked articles are as important as their designation implies, researchers selected 6 articles published in the New England Journal of Medicine and 6 in The Lancet that were either prereleased on the journal's Web site or fast tracked. Twelve "control" articles published in the usual way were matched to the case articles according to journal, topic and year of publication. Forty-two general internists rated the articles, using 10-point scales, on 6 dimensions addressing the articles' importance, ease of applicability and impact on health outcomes. For each dimension the mean score was significantly higher for the case articles than for the control articles. However, in 5 of the 12 matched pairs the control article had a higher mean score than the case article across all the dimensions. The authors suggest that the journals' current practices for choosing articles for accelerated publication may be inconsistent. CMAJ 2002;166(9):1137-43

A related commentary by former New England Journal of Medicine Editor Jerome Kassirer describes the challenges of choosing between a more metred approach to editing and releasing biomedical information, and one of rushing important but sometimes imperfect papers to print. CMAJ 2002;166(9):1151-2

In another commentary André Picard, a health reporter for the Globe and Mail, discusses sifting through the published biomedical "wheat and chaff." He wonders whether the energy put into accelerated publication of a few papers would be better spent weeding out marginal ones. CMAJ 2002;166(9):1153"

Journals help poor countries

CMAJ has joined more than 2000 other scientific publications in promoting free online access for readers in developing nations. The Health InterNetwork Access to Research Initiative is an attempt to provide unfettered access to biomedical information in countries where the annual per capita GNP is less than US$1000 annually. CMAJ 2002;166(13):1705

MEDICAL ASSOCIATIONS

American Medical Association membership drops

Faced with dwindling membership and conflicting views about its mission, the American Medical Association is considering eliminating its individual membership base and transforming itself into an umbrella organization of state and specialty societies. The move would mean that it would collect funds from all groups under the umbrella, not from individual members. Supporters of restructuring note that the national association lost more than 12 000 members last year, and with only 278 000 members now represents less than 30% of American physicians. A special committee examining the restructuring proposal is to report back in June 2003. CMAJ 2002;167(4):386

CMA is MADD

The CMA joined forces with Mothers Against Drunk Driving (MADD) and called for the federal government to reduce Canada's legal blood-alcohol content to .05 from .08. The CMA said Canada is lagging behind countries such as Austria, Australia, Belgium, Denmark, France and Germany, which have already introduced the .05 legal limit. CMAJ 2002;166(1):79

CMA membership reaches new high

Membership in the CMA reached 54 083 in September, the highest total in the association's 135-year history. This count, which includes practising and retired physicians, residents and medical students, marks a gain of 10 000 members during the past 10 years. CMAJ 2002;167(10):1154

CMA past president cleared

The Yukon Court of Appeal ruled that Dr. Allon Reddoch, a past president of the CMA, was not guilty of unprofessional conduct in caring for a patient in 1995. A 16-year-old was admitted to Whitehorse General Hospital with what medical staff thought was food poisoning from smoked fish. However, she had the Yukon's first recorded case of Clostridium botulinum poisoning and eventually died. The Yukon Medical Association decided that Reddoch was guilty of unprofessional conduct just as he was to assume the CMA presidency in 1998; the Court of Appeal eventually disagreed. CMAJ 2002;166(2):227

Change approach to illicit drug use: CMA

Canada spends too much trying to apprehend those who use illicit drugs and not enough trying to treat them, the CMA says. In a March appearance before the Special Senate Committee on Illegal Drugs, CMA President Henry Haddad called for a national strategy that promotes awareness and prevention and emphasizes treatment, not law enforcement. If the strategy is adopted and resources are shifted, says the CMA, the possession of small amounts of marijuana could then be decriminalized with criminal sanctions replaced by fines. The Senate committee was charged primarily with studying Canada's policies on cannabis use. CMAJ 2002;166(9):1197

Dermatologist becomes new CMA president

Fredericton dermatologist Dr. Dana Hanson became the CMA's president in August 2002. Physician workforce shortages, health promotion, and physician health and well-being are high on his agenda, but he says he will be preoccupied for much of his term with the reports on medicare reform from Senator Michael Kirby and Roy Romanow. Hanson, who has served as deputy speaker and speaker at General Council since 1994, succeeded Quebec gastroenterologist Henry Haddad as president.

Hanson's involvement with medical politics began in 1981, the year he established his solo practice in Fredericton. He served in a variety of posts with the New Brunswick Medical Society and was its president in 1992/93. He also received the Canadian Dermatology Association's highest award, the President's Cup, for his work in restructuring its board. CMAJ 2002;167(3):290

Plan to oust Israel from WMA a "hoax"

The CMA's head office was inundated with calls in late April asking it to oppose a move to oust Israel from the World Medical Association (WMA). However, the WMA says the calls were based on a false report in an Israeli newspaper, which it categorically denied. "It was a hoax," Dr. Delon Human, the WMA secretary general, stated in an Apr. 30 email to the CMA.

The rumour started circulating Apr. 24 after the Jerusalem Post reported that "the Israel Medical Association [IMA] is in danger of being ousted from the WMA because of the ongoing political campaign against Israel." The CMA is a member of the WMA and hosted its 1999 annual meeting. CMAJ 2002;166(11):1450

MEDICAL CAREERS (including supply, regulation etc).

Canada depends on IMGs

Data from the 2002 CMA Masterfile list of physicians indicate that 23% of Canada's practising physicians were trained outside the country. The presence of international medical graduates (IMGs) in practice ranges from a low of 12% in Quebec to a high of 56% in Saskatchewan. The split between family physicians and certified specialists trained outside Canada is identical to the split within the overall physician population (52% versus 48%). IMGs tend to be older than the majority of physicians educated here. Forty-seven percent are aged 55 or more, compared with 29% of all physicians. As well, a smaller proportion are female (22% versus 30%). Overall, 31% received their education in Europe and 12% in South Africa. However, of those who graduated since 1990, only 16% were trained in Europe, compared with 43% in South Africa. CMAJ 2002;166(10):1320

Canadian physicians go south

The Canadian Institute for Health Information says that more than 600 physicians left Canada in 2001, a 45% increase over the previous year. This figure, combined with the fact that only 334 physicians returned here, means that Canada suffered a net loss of 275 physicians in 2001. This represents a 68% increase over 2000 and the largest net loss since 1997 when 431 doctors moved south. Most of the physicians moving abroad (72%) were specialists; of those, 64% had graduated from medical school 15 years ago or less. CMAJ 2002;167(6):682

Concern over pediatric workforce

Canada is facing a critical shortage of pediatricians, the Canadian Paediatric Society (CPS) warns. In January the CPS reported that 40% of Canada's pediatricians plan to retire by 2010, and not enough replacements are being trained. "A crisis is looming in Canada's pediatric work force," states the report, which is based on a survey of 1700 pediatricians conducted between 1999 and 2000. The overall number of medical students being trained in Canada declined by 18% during the 1990s before rising again in the past 2 years. As a result, the number of new graduates entering specialty training has been smaller too. CMAJ 2002;166(8):1076

Family physicians and emergency medicine

Since 1982 the College of Family Physicians of Canada has offered emergency medicine certification, CCFP(EM). The objective has been to provide family physicians with extra emergency medicine skills and allow the Royal College of Physicians and Surgeons of Canada to train dedicated emergency specialists. According to a new survey, there is an incongruity between the CCFP(EM) program's objective and the practice choices of its graduates, with many of these certificants are actually practising as if they were emergency medicine specialists. Of the 345 family physicians with emergency medicine certification included in the study, 194 (56%) reported they did "almost all" or "mostly" emergency medicine. Overall, 186 (54%) of the physicians derived less than 10% of their annual patient volume from scheduled family practice visits. CMAJ 2002;167(8):869-70

Family physician workloads

The challenges of physician resource planning are exacerbated by a lack of detailed information on the role played by family physicians, as indicated by practice variations across regions and demographic characteristics. Researchers report the results of a national study of family physician practice patterns undertaken to allow comparisons of clinical workload and range of medical services offered at the regional level. Solo practitioners reported 53.8 total weekly work hours, whereas those practising in multidisciplinary clinics reported 45.0 hours. FP/GPs in the Atlantic and Prairie provinces reported 5.6 and 5.1 more weekly work hours respectively than the national average of 51.4 hours. FP/GPs who served inner-city populations reported 48.6 total weekly work hours, whereas those serving rural populations reported 57.0 hours. FP/GPs practising in less populated provinces and in rural areas reported the highest numbers of work hours, medical services offered and clinical procedures performed. CMAJ 2002;166(11):1407-11

A related commentary examines why there has been a decline in the number of doctors entering family practice. In 2001, less than 28% of medical students made family medicine their first choice for a career, continuing a steady decline from 40% in the early 1990s. CMAJ 2002;166(11):1419-20"

FP residencies left vacant

In April, a record 53 of the 1260 available residency slots remained unfilled after the second iteration of the 2002 residency match; 188 positions — another record — were unfilled following the first round. (The first iteration of the 2000 match ended with 111 positions unfilled, and all but 15 were gone after the second round. This climbed to 153 and 48 positions respectively in 2001.) Family medicine accounts for 83% (44) of positions vacant after the second iteration. The only other specialties with more than 1 vacant spot are psychiatry (3), obstetrics (2) and pathology (2). CMAJ 2002;166(11):1449

"Fast-food medicine"

CMA's annual Physician Resource Questionnaire (PRQ), which tracks data about the evolution of medical practice in Canada, also offers several thousand physicians a chance to vent or rejoice about their profession. In 2002, there was a lot of venting. Many of the complaints concerned the unrelenting demands of medical life. In the 2002 PRQ, respondents were asked for the first time whether their method of practice had changed significantly in the past 2 years, and one-third said it had. Nine percent indicated that they had increased call responsibility, with physicians in the under-35 and 35-44 age groups being somewhat more likely (11% and 12%) to have taken on more call responsibility than physicians in the 55-64 and over-65 age groups (7% and 4%). Conversely, physicians aged 55-64 and those over 65 were more likely (13% and 15%) than those under 35 or aged 35-44 (3% and 8%) to have decreased call responsibilities or to have stopped taking shared call in the previous 2 years. "Too many hours, too many patients, feels like fast-food medicine," commented one respondent. CMAJ 2002;167(4):521-2

Fewer Canadians have own doctor

The proportion of adult Canadians who have a "regular doctor" to provide routine care dropped from 90% in 1999 to 71% in 2001, a recent HealthInsiders survey by PricewaterhouseCoopers indicates. Although 81% of Canadians with a chronic illness reported having a regular doctor, only 62% of those with no chronic illness reported having one in 2001. CMAJ 2002;166(5):646"

Preliminary data from the most recent Statistics Canada Canadian Community Health Survey indicate that the proportion of Canadians aged 12 or older who experienced unmet health care needs in 2000/01 has almost doubled since 1998/99, rising to 12.5% from 6.3%. In 2000/01, females were more likely to report unmet needs than males (14% compared with 10.9%). Older Canadians (65 or older) were less likely to report them (8.1%) than those aged 12 to 34 and 35 to 64 (13.2%). CMAJ 2002;166(9):1198

Family doctor shortfall

Nearly 80% of family doctors in New Brunswick and 78% in Nova Scotia are no longer routinely accepting new patients, the 2001 National Family Physician Workforce Survey indicates. Both figures, the highest in the country, are more than 10 percentage points higher than the national average. The survey, which had a response rate of 51% (14 319 respondents), was conducted by the College of Family Physicians of Canada. CMAJ 2002;166(4):490

New MD charter

The authors of an international physicians' charter say the new document is an attempt to recoup aspects of professionalism that doctors have lost in the wake of growing government and private-sector control over medicine. The Charter on Medical Professionalism is not intended to replace either the CMA Code of Ethics, the CMA's Charter for Physicians, or the Hippocratic Oath. Instead, it is designed to complement existing codes by articulating 3 principles and 10 professional responsibilities that address issues ranging from the primacy of patient welfare to the just distribution of finite resources and the disclosure of errors. "The medical profession is clearly worried about its place in society and its values," says Dr. Richard Cruess, a former dean of medicine at McGill and one of 18 coauthors from around the world. "We believe the majority of doctors are unhappy because they feel powerless to bring about change to make things better." By using this new tool, "we may be able to make changes to preserve the values of medicine." CMAJ 2002;166(7):945

Meakins accepts Oxford post

Dr. Jonathan Meakins, coeditor of the Canadian Journal of Surgery since 1992 and a mainstay of Montreal's surgical community, has been named Nuffield Professor of Surgery at Oxford University. Meakins, the head of surgical services at the McGill University Health Centre, becomes the fourth person — and the first Canadian — to hold the prestigious post, which was created in 1937. CMAJ 2002;167(8):907

Medicine becoming a "female" profession in UK

After years of being encouraged to pursue nontraditional careers, females now account for 60% of British medical students. Now the country's medical association is looking for ways to encourage more men to enter the profession. Last year 3355 women entered medical school in the UK, compared with 2320 men. At the British Medical Association's (BMA) annual meeting in July, delegates were warned that this gender split (59:41) might result in a worsening shortage of MDs because women often leave practice to have children or opt to work part time. In 2001, Canadian medical schools admitted 1137 women and 784 men — the greatest differential ever. CMAJ 2002;167(4):385

Physician role models

Do you have what it takes to be a role model? You probably already are one, whether you realize it or not. Physician role models have been proven to greatly influence the behaviours of medical trainees. Investigators from Johns Hopkins University conducted in-depth interviews with 29 internists highly regarded for their personal qualities and clinical teaching skills. They analyzed the content of the interviews and identified specific characteristics related to being a good role model. CMAJ 2002;167(6):638-43

Pressure to curb MD poaching

The rising international demand for physicians is continuing to fuel fears that developed countries like Canada will siphon too many doctors from poor nations. However, an international conference on the medical workforce made clear that a move away from "plundering" physicians from the developing world is gathering momentum. Codes concerning the ethical recruitment of physicians from underdeveloped countries have already been devised, but their effectiveness remains unclear.

The recruitment issue was also discussed during the World Health Organization's recent World Health Assembly in Geneva, where delegates from developed countries pointed out that the "push" for physicians to leave their native countries is often as strong or stronger than the "pull" from countries like Canada. The World Medical Association (WMA) recently created a committee to examine physician recruitment and to develop a policy concerning the exploitation of doctors recruited to work in other countries. CMAJ 2002;166(13):1707

Quebec's physician shortage?

Quebec says it has a physician shortage, but the rest of Canada disagrees. In May the Canadian Institute of Health Information (CIHI) released statistics indicating that Quebec has more physicians per capita than any other province: 214 per 100 000, compared with 180 in Ontario and 166 in Alberta. Yet the number of physicians in Quebec has increased by only 3.5% over the past 5 years, whereas Ontario and Alberta increased their supply by 8.7% and 16.2% respectively during the same period. Doctors' and patients' groups in Quebec are dismayed that people looking for a physician often can't find one. CMAJ 2002;167(3):288

What physician shortage?

Canada's physician supply peaked in 1993 and has since dropped by 5% to 1987 levels, says a study by the Canadian Institute for Health Information (CIHI). But does this constitute an actual shortage? The study, From Perceived Surplus to Perceived Shortage: What Happened to Canada's Physician Workforce in the 1990s?, released in June, tracks physician-patient ratios over the last decade. Author Ben Chan was careful not to describe the current situation as an "actual shortage" of physicians. Instead, he referred to it as a "shortage perception." He says the 1993 peak set expectations that have proven difficult to meet in subsequent years. CMAJ 2002;167(1):64

Women physicians: achieving balance

The majority (59%) of medical students in Canada are women, as are almost 30% of practising physicians. Many medical women balance the demands of both family and profession, but that balance is often precarious. Like women in other professions, female physicians experience fatigue, stress, guilt and "role strain." Two physician academics discuss impediments to combining these two roles and suggest that the onus is on the academic system to address these issues of gender equity and create an environment that is hospitable to both the men and women of the profession. CMAJ 2002;167(8):877-79

MEDICAL EDUCATION (including research)

Canada's medical student diaspora

There are 5 applicants for every one of the roughly 1800 first-year positions at Canada's 16 medical schools, and, not surprisingly, the number of Canadians heading abroad to study is growing rapidly. Two years ago CMAJ reported Ireland's attempts to woo these students, now Australia has entered the recruiting game. Overall, the number of Canadians currently studying medicine in Ireland and Australia is estimated to be higher than the combined first-year intake at 4 Canadian medical schools: Memorial, Dalhousie, University of Western Ontario and University of Saskatchewan. CMAJ 2002;167(9):1043

First Aboriginal family practice program

The University of British Columbia (UBC) launched Canada's first Aboriginal family practice residency program in July, when Drs. Evan Adams and Shannon Waters begin 2 years of training that will take them to rural Aboriginal communities and a variety of clinical sites in BC's Lower Mainland. CMAJ 2002;166(12):1576

Medical student profiles

Are medical students representative of the Canadian population? Researchers surveyed first-year students at Canadian medical schools outside Quebec and compared their demographic and socioeconomic profiles with Statistics Canada census data. Although the group of students was more ethnically diverse than the Canadian population, certain minorities (black and Aboriginal) were underrepresented and others (Chinese and South Asian) overrepresented. Overall, the students' parents had higher education levels and were more likely to be professionals or high-level managers than the Canadian population aged 45-64. The authors suggest that the ethnic and socioeconomic dissimilarity of Canadian medical students to the general population may affect the future of health care delivery to disadvantaged groups, including rural, Aboriginal and low-income patients. CMAJ 2002;166(8):1023-28

Newfoundland residents get wage parity

In Newfoundland, 15 months of negotiation and debate failed to accomplish what a single threat was able to do: get the provincial government to pay residents the same wages as their counterparts in Nova Scotia. The Professional Association of Internes and Residents of Newfoundland and Labrador (PAIRN) got action by threatening to withdraw provisional services its members provide as locums, including emergency room services.

PAIRN had asked the province to start negotiations in 2001, 3 months before its contract was due to expire. Talks started 6 months later. The main issue was wages. Newfoundland residents, the lowest paid in the country at $32 000 annually, wanted parity with Nova Scotia ($37 000); in Ontario, comparable residents earn $40 000. CMAJ 2002;167(7):789

Rural medical school

Canada's first rural medical school is supposed to welcome its first 55 students in 2004, but not everyone believes that this will be a good thing for Canadian medicine — or even that it will happen. It would be the first medical school in Canada dedicated solely to preparing physicians to practise in rural and remote areas — the places where they are needed most. The school, to be located at Laurentian University in the Northern Ontario mining city of Sudbury, will cost $80 million to set up — money that some believe could be better spent elsewhere. CMAJ 2002;166(4):488

In 2005, the year that students at Northern Ontario's new rural medical school are supposed to finish their first year, James Cook University in Queensland, Australia, will graduate its first class. North Queensland, like Northern Ontario, is a huge, sparsely populated area with a large Aboriginal population. Initially detractors said the school would be unable to attract either faculty or a full complement of students, but the faculty includes both academic and rural clinicians and more than 700 students applied for admission when the school opened in 2000; the original 64 places have increased to 80. CMAJ 2002;166(4):490"

Dr. Roger Strasser, an Australian who helped establish that country's rural health program 10 years ago, was named founding dean of Canada's 17th medical school in April. "This is the best possible solution to help solve Ontario's and Canada's rural and remote workforce problems," he says. "It is a long-term investment. The payoff [will come in] 10 to 15 years — and it isn't just going to be in the physicians who graduate and then stay. We've shown this in Australia ... and it will work here." CMAJ 2002;166(12):1583

Tuition hikes

First-year students attending Canadian medical schools paid an average tuition fee of $7541 during the 2001/02 academic year, data from the Association of Canadian Medical Colleges indicate. This represents a 9.6% increase from the previous year. Quebec residents received the biggest bargain, with average fees of $2885 at their 4 schools. At the other end of the scale is Ontario, with average first-year tuition fees of $12 840. CMAJ 2002;166(5):647

US residents file suit

Fed up with low wages and poor working conditions, 3 American physicians have launched a class-action lawsuit on behalf of some 200 000 fellow residents training in American hospitals. They are challenging the National Resident Matching Program (NRMP) on anti-trust grounds in a suit that names 7 medical organizations and 28 hospitals (see page 1501). The May legal action alleges that the defendants have restrained competition by assigning residents to a single, mandatory employment position through the NRMP, by "artificially depressing and standardizing wages" below competitive levels, and by establishing and complying with anticompetitive rules and regulations of the Accreditation Council for Graduate Medical Education. Most first-year residents earn less than US$40 000 annually and frequently work 100-hour weeks. Many earn less than US$10 an hour while carrying debt loads of more than US$100 000. If successful, the suit could cost the US health system $12 billion annually in increased residents' salaries. CMAJ 2002;166(12):1579

Women need fair shot at research chairs

The nation's universities are being asked to justify why they aren't nominating more women for lucrative Canada Research Chairs (CRC). The CRC steering committee was scheduled to meet in September to put its imprimatur on a plan that will obligate universities to provide a written rationale for the gender distribution of nominees in future competitions for chairs. The committee is headed by the presidents of the nation's 3 granting councils: the Canadian Institutes for Health Research (CIHR), the Natural Sciences and Engineering Research Council and the Social Sciences and Humanities Research Council. Demands for reform have escalated since a recent CRC study indicated that women have been appointed to only 15% of the available chairs, even though they comprise 25% of the academic pool. The discrepancy is even more pronounced in health care. In disciplines falling under CIHR, women have received only 11.5% (14/122) of the "Tier I" chairs that free "star" researchers from teaching duties with financial support of $1.4 million over 7 years. CMAJ 2002;167(8):910

MEDICAL ERROR

Canada to get largest adverse-event database

Canada will have access to 350 000 adverse event reports annually through the world's largest repository of such data. Health Canada's acting director general, Dr. Chris Turner, says an agreement providing access is slated to be signed with the US Food and Drug Administration in the fall 2002. The database, which includes information from Europe, should be accessible by early 2003. Negotiations began 4 years ago. Canada's small population makes it difficult to assess the risk a new drug may pose. The larger database will provide Health Canada with more accurate information so it can issue timely warnings and advisories, or withdraw a drug. Creation of a database was one of 17 recommendations directed at Health Canada after a coroner's inquest into the death of 15-year-old Oakville, Ont., resident Vanessa Young. She died of a cardiac arrhythmia in March 2000 while taking cisapride (Prepulsid) to treat digestive problems. The drug, contraindicated for patients like Young who had bulimia, was pulled from the Canadian market in August 2000. CMAJ 2002;167(7):790

Fear of legal action prevents reporting

Fear of legal action is the biggest barrier to increased reporting of adverse events, says a coauthor of a new report aimed at reducing medical error. And increased reporting is the key to reducing medical errors that account for 10 000 lives annually in Canada, states the report. Building a Safer System, released in September by the National Steering Committee on Patient Safety, recommends changing evidence acts so that "data and opinions associated with patient-safety and quality-improvement discussions, related documents and reports are protected from disclosure." Dr. John Wade, chair of the steering committee, emphasized that "people who have committed a criminal act have to be held accountable," but less than 1% of adverse events involve criminal negligence. The report calls for a new National Patient Safety Institute at an initial cost of $10 million annually for 5 years. It would promote changes to enhance reporting, recommend new practices or technologies, and identify necessary research. The report has been endorsed by 24 national groups, including the CMA and Canadian Medical Protective Association. CMAJ 2002;167(9):1047

No ban on reuse of single-use devices

The widespread reuse of single-use medical devices within Canadian hospitals is unsafe and needs to be regulated. In December 2001, there was a $27.5-million settlement in a case involving a Toronto neurologist whose patients developed hepatitis B after undergoing electroencephalography. The tests were conducted by a clinician infected with the virus, and some electrodes used in the tests were reused.

The reuse of such devices as surgical drills, biopsy forceps, catheters and laparoscopy scissors is common in many hospitals, yet the cleaning and sterilizing protocols differ greatly. CMAJ 2002;166(7):943

Nursing shortage a factor

An acute and growing shortage of nurses in US hospitals has been a factor in almost one-quarter of all adverse events resulting in death, injury or permanent loss of function over the past 5 years, the Joint Commission on Accreditation of Healthcare Organizations reports. The commission, which inspects and accredits American hospitals, says inadequate nurse staffing levels contributed to 42% of surgery-related incidents, 25% of transfusion problems and 19% of medication errors during the period. They are also "a major factor in emergency department overcrowding and in the cancellation of elective surgeries." The report, Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis, concludes that with more than 126 000 acute care nursing positions currently vacant and with an estimated shortfall of some 400 000 nurses in the US by 2020, "what is already a bad situation only threatens to worsen." CMAJ 2002;167(10):1159

Quebec moves to disclose

Mysteries and secrecy surrounding medical errors will soon be a thing of the past if the Quebec College of Physicians and Surgeons has its way. In an unprecedented step, the college has moved to change its code of conduct to require doctors to reveal errors to patients as quickly as possible or face disciplinary action. The amendments are expected to be ratified by Quebec's National Assembly by September. CMAJ 2002;166(6):800

Study to assess adverse events

The largest-ever study of adverse events in Canadian hospitals will be launched this fall in 5 provinces. Forty researchers and reviewers will tally and examine the incidence of adverse events in 20 Canadian acute care hospitals with the aim of finding ways to reduce their occurrence. The researchers will also examine whether the available data and current methods of record-keeping are adequate for monitoring and analyzing adverse events. CMAJ 2002;167(2):181

Talk, don't hide

A profound change in the culture surrounding medical error that is shifting the emphasis from silence to safety is the goal of a new program at St. Paul's Hospital in Vancouver, the only Canadian centre participating in a collaborative project of the Boston-based Institute for Healthcare Improvement (IHI). St. Paul's is encouraging its staff to discuss errors and near misses, and has set specific goals such as reducing adverse drug events by 75%. The IHI estimates that 4% of hospitalized patients in the US suffer a "serious adverse event" and that up to 10% of patients experience an adverse drug event. CMAJ 2002;166(4):496

MEDICINE AND THE LAW

Emergency re-routing

In January 2000, 18-year-old Joshua Fleuelling died following an asthma attack. He had experienced cardiac arrest while being transported by ambulance to hospital, although not the nearest hospital because that institution was on "critical care bypass." A lawyer examines the policies of critical care bypass in a legal framework and discusses the legal dilemmas that arise when the physician's duty to care confronts real-world problems of staff and equipment shortages and emergency room overcrowding. She says existing judicial and academic opinions seem to suggest that the standard of care for physicians is sufficiently flexible to accommodate any reasonable medical decisions made in response to overcrowding. However, she also warns that liability issues may be more complex for hospitals than physicians. CMAJ 2002;166(4):465-9

A related commentary provides an emergency physician's perspective on the challenges of weighing the potential harms of having patients diverted to another hospital against those of accepting critically ill patients and possibly jeopardizing the care of patients already in the overcrowded emergency department. CMAJ 2002;166(4):445-6

Huge class-action settlement

A recent $27.5-million class-action settlement involving a Toronto-area physician has left some neurologists concerned about potential damage to the specialty's reputation. The December settlement, the largest of its kind in Canadian medicolegal history, will see payments made to up to 15 000 patients who underwent electroencephalograms (EEGs) at 6 Toronto-area clinics between January 1990 and March 1996; about 75 of them subsequently developed hepatitis B. The clinics were operated by Dr. Ronald Wilson. CMAJ 2002;166(3):363-4

Just say No

The Canadian Medical Protective Association (CMPA) has warned its 60 000 members against signing declarations that allow patients to use marijuana for medicinal purposes if they do not feel "qualified" to assess the drug's relative risks and benefits. The CMPA says the federal Marihuana Medical Access Regulations plan an "unacceptable burden on member physicians to inform themselves of medical marijuana in each patient's case, as well as the relative risks and benefits of the drug and what dosage would be appropriate." CMAJ 2002;166(1):83

Lawyers trying to reform malpractice

The Holland Access to Justice in Medical Malpractice Group, a loose association of about 10 lawyers, is tackling malpractice issues such as the sharing of expert witnesses, the cost of future care and the impact of limitation periods that vary across the country. In effect, the group has put the entire culture of malpractice litigation under the microscope. The creation of the group is somewhat surprising, given the adversarial relationship that typically exists between lawyers on the 2 sides, but it has already made headway on the use of expert witnesses. Usually, both sides hire their own experts, who then duel over the cost of future care, life expectancy and the other issues common to malpractice cases. However, this increases both costs and the time a case requires. The group is developing a panel of experts in areas from orthopedics to economics who will be able to work with both parties. The nonpartisan experts will be paid jointly; in 2000, the CMPA spent $9.2 million on expert witnesses. CMAJ 2002;167(7):791

MD's $2.5-million libel award upheld

Dr. Frans Leenen's battle with the CBC is finally over. In February the Supreme Court of Canada denied the broadcaster leave to appeal a lower-court ruling awarding Leenen almost $2.5 million in libel damages, costs and interest, the most in Canadian history. When the case was launched in 1996, Leenen had been willing to settle it for $10 000 and an apology. It centred on the depiction of Leenen, director of the Hypertension Unit at the University of Ottawa Heart Institute, on an investigative program, the fifth estate. It dealt with the safety of a calcium-channel blocker, nifedipine, and Leenen's association with it. CMAJ 2002;166(6):794

US malpractice premiums soar

After years of relative stability, medical malpractice premiums are soaring across the US, forcing thousands of physicians to "go bare," shut their offices, relocate or accept double-digit increases. In New York, Texas and Florida, where litigation is most rampant, insurers are increasing their rates by 30% to 50%. In southeast Florida, higher-risk specialists such as obstetricians are now paying $200 000 a year for $1 million in coverage. Neurosurgeons in Long Island, NY, who are already paying $150 000 annually for $1 million in coverage, have already been told they will be paying even more. In Corpus Christi, Texas, a pediatric neurosurgeon saw his premium increase from $32 000 in 1999 to nearly $120 000 last year. Not only is insurance becoming unaffordable, it is also becoming unavailable in some regions. Three insurers have recently stopped insuring physicians. St. Paul Companies of Minnesota has refused to renew policies for 42 000 doctors spread across the country. PHICO insurance company liquidated, leaving hundreds of Vermont physicians uninsured. And the Princeton Insurance Company opted out of the medical liability market in Pennsylvania, leaving more than 1000 physicians scrambling for coverage. CMAJ 2002;166(9):1195

US MDs to sue HMOs

Thanks to a recent court ruling, 600 000 US physicians have been given the right to sue some of the nation's largest HMOs for fraud and racketeering. The ruling allows the doctors, who are supported by 5 state medical societies, to press a class-action suit claiming that they have been systematically defrauded by HMOs that arbitrarily and routinely cut fees. The amount of the claim has not yet been determined, but lawyers say hundreds of millions of dollars have been swallowed by HMOs that "downcode" doctors' billings, retroactively deny claims for medically necessary services and offer bonuses to claims reviewers who delay or deny claims. For instance, lawyers allege that a "25-minute visit of moderate/high complexity with an established patient" is commonly downcoded to a 15-minute visit of low/moderate complexity, which saves the HMO $50 or more. CMAJ 2002;167(10):1157

MENTAL HEALTH

Primary care of depression

The World Health Organization has predicted that by 2020 major depression will be second only to heart disease as a contributor to the global burden of disease. Depression is common, is associated with high morbidity and is often difficult to recognize. In the last 20 years, our understanding of its causes has improved and, with this, our capacity to offer effective treatment. Ronald Remick, a psychiatrist from British Columbia, offers a clinical update on the diagnosis and management of major depressive disorder in the primary care setting. CMAJ 2002;167(11):1253-60

NURSING AND ALLIED HEALTH PROFESSIONALS

High health risk

Health care workers are 1.5 times more likely to be absent from work due to illness or injury, a new report indicates. The Canadian Institute for Health Information report reveals that 7.2% of Canadians in full-time health care occupations were absent for health reasons during each week in 2000, compared with 4.8% of workers in other fields. On average, Canada's health care workers are absent from work 11.8 days a year, other workers 6.7 days. If the 2 rates were the same, says the report, it would put more than 13 700 "extra" full-time health care workers on the job. It would also help address the nursing shortage by providing the equivalent of almost 5500 extra nurses. CMAJ 2002;166(3):365

Male nurse heads CNA

The first-ever male president of the Canadian Nurses Association (CNA) hopes his presence will help convince more men to consider nursing as a career. "We have to get past our thinking about what's men's work and what's women's work," says Rob Calnan, a nurse educator and clinician from Victoria. When he joined the profession 30 years ago, about 2% of Canadian nurses were male. Today men account for about 5% of the total, with Quebec leading the way with 15%. Calnan, 48, is the nurse manager for burns, plastic surgery, complex wounds, otolaryngology and urology at the Royal Jubilee Hospital and a teacher at the University of Victoria. He became the first male president in the 94-year history of the CNA in June. CMAJ 2002;167(4):385

New Mexico psychologist get prescribing privileges

New Mexico is the first US state to grant prescribing privileges to psychologists. The legislation, approved in March, is a response to the state's shortage of psychiatrists. There are only 18 psychiatrists serving the 72% of New Mexicans who live outside Albuquerque and Santa Fe, and patients are waiting between 6 weeks and 5 months to see one of them. Before prescribing psychotropic drugs, psychologists must complete 450 hours of course work, a 100-patient practicum under MD supervision, and pass a national exam. They will then receive a 2-year licence that lets them prescribe under a doctor's supervision. If the physician approves and the psychologist's prescribing records pass an independent peer review, the psychologist can apply to prescribe independently after 2 years. Four other states have similar legislation pending, and 31 state associations representing psychologists are lobbying for it. CMAJ 2002;166(10):1327

Nurse shortfall of 78 000 by 2011

South of the border, nurses are being lured to jobs with signing bonuses of up to US$30 000. In Canada, however, an improved work environment appears to be a more important recruiting tool. In an August report, the Canadian Nurses Association (CNA) says nurses here want full-time employment, appropriate workloads, involvement in decision-making and educational opportunities. During the cutbacks of the 1990s, many nurses were forced into part-time or casual jobs, and by the late 1990s 48% of nursing positions provided only part-time work. Desperate for stable employment, up to 15% of new Canadian graduates now move directly to the US; the CNA, which represents 115 000 nurses, wants to reduce this to 5%. It predicts that the country faces a shortfall of 78 000 nurses by 2011 and 113 000 by 2016. "Physicians should ponder what this will mean to them and their patients," said CNA President Rob Calnan. CMAJ 2002;167(5):535

NUTRITION

Food and behaviour

Can food help modulate mood and behaviour? A review of the possible psychopharmacologic effect of several nutrients looks at the possible mild antidepressant effects of S-adenosylmethionine (SAMe), folic acid and tryptophan. The author then reviews the relation between carbohydrate consumption and sedation, the myth that sugar causes hyperactivity in children, and the developing understanding of the role of dietary fat in neural function. CMAJ 2002;166(2):205-5

Functional foods

Many consumers are looking to food to be not only simple nutrition but also a potential source of health benefits. A researcher explains that "functional foods" are distinct from fortified foods and natural health supplements in that they contain bioactive elements that may reduce the risk of disease. He reviews the regulations regarding health claims for such functional foods in Canada and the United States and describes several examples, including oat bran fibre, soy protein, fish oil fatty acids, and plant sterols and stanols. CMAJ 2002;166(12):1555-63

GM food regulations needed

Canada must boost its regulatory control over genetically modified (GM) foods, but mandatory labelling won't be part of the scheme, a new federal report suggested in summer 2002. "Although the products that have entered the market appear to be safe by all scientific measures, we don't think the system is up to the challenge it's going to face in the next while," says Dr. Peter Phillips, cochair of the Biotechnology Advisory Council of Canada's Committee on GM Foods. The report, Improving the Regulation of Genetically Modified Foods and Other Novel Foods in Canada, says there's a need to standardize review procedures, to adopt a "precautionary" approach at all stages of development and commercialization of new biotechnology products, and to conduct more research into the long-term impact of GM foods on human health or the environment. CMAJ 2002;167(9):1046

How much should we eat?

Physicians are frequently confronted with obese and overweight patients who do not lose weight, despite insisting that they are following their prescribed diets. The real reason underlying this paradox is that the current methods for assessing energy intake are flawed, and they underestimate actual energy intake. This article reviews new methods for measuring the energy content of foods and addresses the problem of energy expenditure in obese people. The authors hope that by understanding these components of obesity, physicians may be better able to manage their obese patients and to advise dietitians and nutritionists. CMAJ 2002;166(6):767-70

Omega-3 fatty acids and heart health

Low rates of cardiovascular disease in some populations that eat large amounts of fish, such as the Greenland Inuit, have prompted research into the possible cardiovascular benefits of the omega-3 fatty acids found in fish oils. An author reviews the dietary sources and potential antithrombotic effects of omega-3 fatty acids and discusses a practical approach to the use of these agents. CMAJ 2002;166(2):608-15

Vitamin D insufficiency

Canadians living in northern latitudes may be at increased risk of vitamin D insufficiency and its associated risk of fractures caused by osteoporosis because they are not exposed to enough sunshine, a source of vitamin D. Researchers investigated the prevalence of vitamin D insufficiency in a group of adults (60 men, 128 women) in Calgary aged 27-89 years who were otherwise healthy and not taking vitamin D supplements. Blood samples were collected every 3 months for a year and tested for several metabolic markers, including vitamin D metabolites, calcium and parathyroid hormone. The authors found that a startling 97% of study participants had vitamin D insufficiency at some point during the year. Even if a common but more conservative threshold is used, about one-third of otherwise healthy subjects had vitamin D insufficiency. As expected, the mean level of vitamin D rose in the spring and summer and declined in the fall, when the subjects were exposed to less frequent, and intense, sunlight. The authors call for more aggressive vitamin D supplementation in the general population. CMAJ 2002;166(12):1517-24

A related commentary echoes this recommendation and calls for an even higher daily supplement of vitamin D for all adults. CMAJ 2002;166(12):1241-2

OBESITY

The Canadian obesity epidemic, 1985-1998

A commentary on Canada's obesity pandemic presents several new surveillance maps that graphically depict the progression of obesity in this country since 1985. The maps graphically show how all Canadian provinces have experienced increases in the prevalence of obesity. By 1998, only Quebec and BC had prevalences below 15%. CMAJ 2002;166(8):1039-40

Obesity in the US

Fast food and larger portions of it are taking a toll in the US, where the surgeon general says 60% of adults are overweight or obese, as are nearly 13% of children. "Being overweight [or] obese may soon cause as much preventable disease and death as cigarette smoking," says Surgeon General David Satcher. Some 300 000 deaths are already associated with obesity and excess weight in the US every year. Tobacco use is associated with about 400 000 deaths annually. The prevalence of excess weight and obesity has nearly doubled among children and adolescents since 1980, and is increasing in both sexes and among all adults. The trends are already associated with major increases in the prevalence of conditions such as asthma and type 2 diabetes mellitus in children. CMAJ 2002;166(6):642

OCCUPATIONAL HEALTH

Post-traumatic stress and journalists

For years firefighters, police, ambulance attendants and other emergency and military personnel have been offered ways to cope with the carnage and mayhem they witness. However, journalists who often witness the same atrocities haven't received any help. But that's changing with Newscoverage Unlimited, an educational, non-profit organization founded in 2000 by Montreal journalist Robert Frank. It trains journalists to help each other with post-traumatic stress disorder, depression or drug dependency. CMAJ 2002;166(13):1704

PEDIATRICS

Car safety for kids

More Canadian children die of road traffic injuries than from any other cause, and nonuse or misuse of child restraints is a major contributing factor. An overview of the current knowledge about child safety seats discusses controversies relating to their use. While written primarily for clinicians interested in injury prevention, counselling, advocacy, research and treatment of child occupants in car crashes, parents may also learn a great deal from this comprehensive study about how to ensure that children ride safely. CMAJ 2002;167(7):769-73

Death from circumcision

The death of a 5-week-old British Columbia boy 2 days after he was circumcised will further marginalize the procedure in Canada, an international lobby group says. Doctors Opposing Circumcision described the August 2002 death of the Penticton boy, apparently from bleeding-related complications, as "tragic and unnecessary. The only good that could possibly emerge is that more parents and physicians will now think twice before proceeding." The Canadian Paediatric Society statement on neonatal circumcision in 1996 concluded that "circumcision of newborns should not be routinely performed." That statement will be reviewed in light of the boy's death. CMAJ 2002;167(7):789

Debate over autism treatment

The British Columbia Court of Appeal has upheld a ruling that the province violated the Canadian Charter of Rights and Freedoms by refusing to fund an early-intervention treatment program for autistic children. The treatment costs about $60 000 per child per year. Parents of autistic children filed their suit in 1998, and 2 years later a BC Supreme Court judge declared the treatment — Lovaas therapy — medically necessary. The province appealed, but last month's unanimous appeal court ruling concluded that autism "is a medical disability just as cancer is, and both require treatment." The court rejected the government's claim that it was unable to pay for the treatment and also changed the maximum age for eligibility from 6 years to 19 years. It is estimated that there are 1400 autistic children under age 19 living in BC. CMAJ 2002;167(11):1278

Immunization viewed as important

Data collected for the Canadian Public Health Association indicate that 92% of Canadian parents believe it is important that their children be vaccinated. Similarly, 91% agree that childhood vaccines take pressure off the health care system and 90% think all standard vaccines should be administered to all children. A small proportion of parents (5%) think vaccination is unnecessary because they think vaccine-preventable diseases have been completely eradicated. Although 92% of respondents think the government should fund all vaccinations, 96% indicated that they would pay personally to vaccinate their children. CMAJ 2002;167(1):69

Mortality in neonatal ICUs

Most studies looking at mortality rates in neonatal intensive care units (NICUs) have looked at specific populations such as low-birth-weight infants. In contrast, a new study looked at the rates and causes of death among all 19 265 infants admitted to 17 tertiary care Canadian NICUs between January 1996 and October 1997. Overall, there were 795 deaths (4%); 40% of them occurred within 2 days after admission to the NICU. Common conditions associated with death were birth at a different hospital from the NICU (340 or 42%), congenital anomalies (270 or 34%), infection (108 or 14%) and hypoxic-ischemic encephalopathy (128 or 16%). The researchers point out the importance of careful risk adjustment in studies of the differences in patient outcomes among hospitals. CMAJ 2002;166(2):173-8

A related commentary praises the study as being of "exemplary quality" but points to the need for careful risk adjustment in studies on the differences in patient outcomes among hospitals. CMAJ 2002;166(2):191-2

Another commentary reviews the history of quality improvement studies in facilities such as health care institutions. It challenges the idea of maintaining institutional anonymity when publishing studies related to important issues such as variations in mortality occurring at different public facilities. CMAJ 2002;166(2):193-4

New vaccine for streptococcus pneumoniae

A new vaccine for streptococcus pneumoniae infection in infants and small children has been licensed in Canada and the United States. The US Centers for Disease Control and Prevention recommends that all children aged 2 to 23 months be vaccinated; Canada has yet to make recommendations on the use of this vaccine. The risk of invasive pneumococcal disease is highest during the first 2 years of life, with an estimated incidence rate of 83 to 161.2 per 100 000 in Canada. This is comparable to the estimate for pertussis among nonvaccinated children (153 per 100 000). CMAJ 2002;166(2):220

Overweight, inactive kids worry Health Canada

In April, as the World Health Organization (WHO) began warning that physical inactivity causes 2 million deaths a year, Health Canada unveiled a plan to increase physical activity among children by at least 30 minutes a day. WHO says sedentary lifestyles may now rank among the world's 10 leading causes of death and disability, and may be causing a rapid rise in illnesses such as cardiovascular disease and diabetes. Canada's Health Minister Anne McLellan announced that she was setting her sights on combating childhood obesity. Recent research reveals that 15% of Canadian boys carried excess weight in 1981, but this had grown to 28.8% by 1996; among girls, it increased from 15% to 23.6%. The prevalence of obesity in children more than doubled over that period, from 5% to 13.5% for boys and 11.8% for girls. CMAJ 2002;166(11):1450

Pediatric liver transplant outcomes improving

Researchers at the University of Western Ontario, which performed its first pediatric liver transplant in 1984, tracked the survival rates and long-term outcomes of more than 100 pediatric patients who received new livers. The authors conclude that outcomes continue to improve. They studied all pediatric patients who received liver transplants between April 1984 and December 1999, examining outcomes such as patient survival, retransplantation rates, and overall growth and development. Time periods were subdivided: April 1984 to July 1988 (period 1), August 1988 to December 1993 (period 2) and January 1994 to December 1999 (period 3). The proportion of recipients surviving for a year after transplantation increased from 69% in period 1 to 87% in period 2 and 93% in period 3. Retransplantation rates were 31%, 13% and 17% during the 3 periods. For patients requiring retransplantation, the one-year survival rate increased over time, from 33% in period 1 to 83% and 100%, respectively, in periods 2 and 3. The authors attribute the progress to improved surgical techniques, perioperative care and, to a lesser extent, immunosuppressive therapy. CMAJ 2002;166(13):1663-71

Sedentary "tweens" at higher risk

The sedentary lifestyle of Canadian "tweens" is putting them at risk of developing heart disease at a younger age than members of previous generations, a new report from the Canadian Heart and Stroke Foundation indicates. It warns that a poor diet and inadequate exercise among children aged 9 to 12 could "put them in the fast lane" for heart disease and stroke by the time they are 30. In interviews with 500 tweens across the country, researchers found that only 14% eat enough fruit and vegetables, while just over half exercise regularly. CMAJ 2002;166(8):1075

Scooting into ER

Thousands of people, most of them under the age of 15, seek emergency care each year for scooter-related injuries that include fractures, dislocations, lacerations, contusions and sprains. A Public Health author discusses the challenge of encouraging the safe use of scooters while not discouraging kids from being physically active. CMAJ 2002;167(1):55

PHARMACEUTICALS

Antibiotic prescribing drops

An Ipsos-Reid poll determined that more than half (53%) of adult Canadians were prescribed an antibiotic in the last 3 years, a drop from 62% in 2000. The poll, conducted for the National Information Program on Antibiotics, found that 89% of those aged 55 or older who had a prescription for an antibiotic filled recently finished all the medication, even if they felt better in a couple of days. This compares with just 71% of those aged 18 to 34. Women were somewhat more likely than men to finish their medication (83% versus 76%). Almost two-thirds (64%) of noncompliant patients said "feeling better" was the reason they did not take all the drug that was prescribed. CMAJ 2002;166(6):798

Bugs bite back

Antibiotic resistance has increased rapidly during the last decade, creating a serious threat to the treatment of infectious diseases, and Canada is no exception to this phenomenon. A review article written by the chair of the Canadian Committee on Antibiotic Resistance details how bacteria are becoming more resilient and how their capacity to change is posing a greater threat to patients. While the number of antibiotic prescriptions decreased by 11% from 1995 to 2000, resistance rates continue to rise. Treatment of resistant bacteria now costs the health care system as much as $200 million a year. CMAJ 2002;167(7):885-91

CPS overdose information often poor

When treating a patient with a potential drug overdose, a physician's first step is often to reach for the Compendium of Pharmaceuticals and Specialties (CPS) — the physician's 2000-page bible for prescribing thousands of drugs. But does it prescribe the right steps to follow after a drug overdose? In a study of overdose instructions provided by CPS for 119 drugs within 10 classes of medication, researchers from the BC Drug and Poison Information Centre found that for half the drugs the instructions contained either misleading or dangerous advice. "Several monographs contained advice that was archaic if not bizarre," they said. In all, 51% of the drug monographs contained poor advice, and in another 29% it was only fair. The authors conclude that physicians seeking advice on overdoses should consult authoritative sources such as local poison control centres or computerized databases, not the CPS. They also say that many overdose recommendations in the CPS should be rewritten. If they are not, "the overdose management sections could be eliminated." CMAJ 2002;167(9):992-6

COX-2 inhibitors

The cyclooxygenase-2 (COX-2) selective nonsteroidal anti-inflammatory drugs (NSAIDs) celecoxib (Celebrex) and rofecoxib (Vioxx) were first listed on the Ontario Drug Benefit formulary as "limited use" products on Apr. 17, 2000. The "limited use" designation indicated the products would only be covered as a benefit if previous NSAID therapy had failed or was not tolerated by a patient. However, based on their examination of drug claims data, researchers found that most of the patients among the initial users of COX-2 inhibitors did not have a prescription claim for another NSAID in the 4 months preceding their first COX-2 prescription. The authors state that the listing of the COX-2 inhibitors had a "substantial and immediate impact on expenditures on NSAIDs," and accounted for 48% of prescriptions and 66% of expenditures for NSAIDs in the post-listing period (Apr. 18 to Nov. 30, 2000). CMAJ 2002;167(10):1125-6

A related editorial describes the appropriate use of these medicines, the safety and efficacy of NSAIDs and the advantages and disadvantages of COX-2 inhibitors. CMAJ 2002;167(10):1131-7

DTC ads raise sales

New research indicates that direct-to-consumer advertising of prescription drugs via television, magazines and billboards has become one of the hottest revenue producers in the history of mass media in the US, giving some drugs the kind of instant brand recognition previously reserved for autos, soft drinks and detergents. The National Institute for Health Care Management, a Washington-based nonprofit research group, says increased sales of the 50 drugs with the largest advertising budgets accounted for 47.8% of the US$20.8-billion increase in retail spending on prescription drugs from 1999 to 2000. Increases in the sales of all other prescription drugs — approximately 9850 of them — accounted for the rest. CMAJ 2002;167(3):289

Health Canada targets postmarket surveillance

After years of complaints about inconsistent approaches to follow-up and surveillance once a drug has been marketed, Health Canada has created a Marketed Health Products Directorate (MHPD) to provide postmarket monitoring of products ranging from drugs and vaccines to foods that make health claims. MHPD will bring all surveillance under one roof, allowing for a consistent approach and an expanded mandate. The ultimate goal is to make it easier to report adverse events and identify trends.

The new directorate has the money to build programs and hire 50 staff, with $6 million having been added to the existing $4.5-million set aside for postmarket surveillance. It will also incorporate postmarket surveillance across 3 Health Canada branches, and take on 2 additional roles — active surveillance and reducing the number of medication errors. CMAJ 2002;16(12):1580

Prescription drug cost-sharing

As a cost-saving measure, British Columbia introduced reference-based pricing in January 1997 wherein the province would cover only the least expensive drug in a medication class (patients prescribed more expensive drugs would have to pay the difference). Using data from provincial health and prescription drug databases, researchers studied the use of angiotensin-converting enzyme (ACE) inhibitors by elderly patients for the 2 years before and the year after reference-based pricing was introduced. They found a decline of 29% in the use of higher-priced medications immediately following the change and estimated the government's savings at $6.7 million in the first year alone. Although the use of antihypertensives was unchanged, 11% less people were using an ACE inhibitor after the policy change. Low-income patients were more likely than high-income patients to stop all antihypertensive therapy (odds ratio 1.65). CMAJ 2002;166(6):737-45

A related commentary discusses whether the decline in ACE inhibitor use may have an impact on the already undertreated problem of hypertension. CMAJ 2002;166(6):763-4

Provincial drug benefits

Many physicians are unclear why some prescriptions they write for patients will be covered by their provincial drug benefit plan and others will not. This article aims to demystify the process by giving an "insider's view" from a member of the Therapeutics Committee for the province of Ontario. The author reminds us that although the cost-conscious committee is concerned with a drug's price, in determining "cost-effectiveness" it is equally concerned with the drug's relative "effectiveness." He reviews some of the reasons why a drug may not be covered for general use by the Ontario Drug Benefits Program and some of the pros and cons of restricting the prescribing and use of certain medications. CMAJ 2002;166(1):44-47

Reining in drug costs

Reference-based pricing for drug reimbursement has been a partial success in British Columbia. The extra cost of a more expensive drug in a class that includes other cheaper, equally effective options is transferred to the patient. If a physician feels that the more expensive drug is necessary, he or she may request an exemption. Although studies have shown that this approach has economic benefits and appears clinically safe, the savings are smaller than anticipated. As drug costs continue to escalate, more effective price control is needed. Researchers borrow an example from German reference-based pricing, the "physician drug budget," and suggest that with modifications its implementation might be the answer to increasing pharmaceutical expenses. CMAJ 2002;167(11):1250-1

Speed up approvals

It's time for Ottawa to deliver on its long-promised overhaul of the drug-review system and approval process so that Canadians can get readier access to new medicines, a coalition of consumer-based advocacy groups says. Although the health minister embraced recommended reforms nearly 2 years ago, the department's record is actually getting worse, the cochairs of the Canadians for Best Medicines said at the Second National Summit on Reform of the Drug Review System that was held in January.

Health Canada's stated target for drug approvals is 355 days, but it took an average of 743 days to review a drug in 2000, 152 days longer than in 1999. CMAJ 2002;166(5):644

US drug industry bans expensive freebies

The new marketing code of ethics for drug detailers in the US has outlawed a battery of expensive giveaways, while the revised Canadian code has simply expanded on what giveaways are allowed and increased potential fines facing drug companies. The new voluntary code from the Pharmaceutical Research and Manufacturers of America (PhRMA), which went into effect July 1, states that all interactions between physicians and detailers must be focused on information. This means that tickets to sporting events and Broadway plays, free music CDs, rounds of golf or expensive dinners are now forbidden. The code also prohibits free travel to medical conferences (except for speakers) and payment for attending CME events. This is PhRMA's first code — previously it followed American Medical Association (AMA) guidelines. US pharmaceutical companies spend about $16 billion annually on drug promotion.

In Canada, a revised code for members of Canada's Research-based Pharmaceutical Companies (Rx&D) doesn't limit freebies but it does get more precise about limits. For example, it spells out how to pay physician consultants and fund physician travel to international health education events. The maximum penalty for violating the Canadian code has tripled to $15 000. CMAJ 2002;167(5):522

PUBLIC HEALTH

Brother, can you spare a dime?

Panhandlers are a common sight in many Canadian cities and decisions about whether or not to give them money are often based on assumptions about how the money will be used. In a study of panhandlers in downtown Toronto, researchers found that even though the amount of money panhandlers spent on alcohol and illicit drugs was "significant," it was "much lower than some have suggested." The authors noted that the single largest reported expense was food, followed by tobacco, then alcohol/illicit drugs. CMAJ 2002;167(5):477-9

Canada's first vCJD case

The first Canadian death attributed to variant Creutzfeldt-Jakob disease (vCJD) was reported in August, and health officials in Saskatoon say a coordinated information campaign minimized public anxiety about it. The patient, whom Health Canada identified as "a male under the age of 50," died in June. The Saskatoon Star-Phoenix later reported that the patient was a 37-year-old podiatrist who had studied in the UK from 1987 to 1990. Health Canada said the man had "multiple stays" in the UK in the late 1980s and had eaten beef — considered the source of the UK's vCJD outbreak in the 1990s.

About 135 cases of vCJD have been reported, 125 in the UK. "There is no evidence that mad cow disease has entered the Canadian food supply and therefore we can reassure the public the person did not acquire the disease in Canada," stated Health Canada. CMAJ 2002;167(6):680

Canada's system beset by problems

An unpublished report obtained by CMAJ indicates that Canada's public health infrastructure may be overwhelmed if it faces more than one major public health crisis at once. The report was completed in September 2000, a year before the possibility of major public health threats was raised by the Sept. 11 terrorist attacks in the US and 4 months after a contaminated water supply claimed 7 lives in Walkerton, Ont. "There appears to be agreement that only one crisis can be managed at a time," it says. The 65-page report, prepared for the Federal, Provincial and Territorial Advisory Committee on Population Health, was never made public. CMAJ 2002;166(10):1319

CJD fears continue in UK

New cases of variant Creutzfeldt-Jakob disease (vCJD) in the United Kingdom and Western Europe have prompted the European Parliament to implement more stringent measures to protect consumers. The European Commission is now monitoring its 15 member countries for compliance, and countries that fail to implement safeguards face fines. The human form of bovine spongiform encephalopathy (BSE) had killed 109 people in the UK as of March 2002, with 5 of the deaths occurring this year. There have also been 4 deaths in France and 1 in Italy. CMAJ 2002;166(9):1197

Death behind bars

Many who enter Canada's prison system never have an opportunity to leave. Previous data on causes of death during incarceration have largely been extrapolated from the United States. Canadian researchers studied the causes of death among people in custody in Ontario over a 10-year period. The authors found that a total of 308 inmates died in custody between 1990 and 1999. Of the 283 deaths involving men, well over half (168) were due to violent causes: suicide by strangulation (90), poisoning or toxic effect (48), and homicide (16). Natural causes accounted for 115 of the deaths, with cardiovascular disease being the most common cause (62) followed distantly by cancer (18 cases).

They found a disproportionately high risk of violent death, with fatal overdose being 20 to 50 times more common than in the general male population, and a surprisingly high number of cardiovascular deaths in young men. CMAJ 2002;167(10):1109-13

An associated commentary compares these findings with previous findings from around the world and recommend further work be done to find out more about individual risk factors, precursors of deaths and preventive factors. CMAJ 2002;167(10):1127-8

Deaths and injuries from road rage

An examination of Canadian newspaper reports between 1998 and 2000 reveals there were 59 separate cases of road rage reported in 96 articles. Researchers found that most reported road-rage cases occurred because of cutting in and out, lane changes, disputes over parking spots and rude gestures. The authors found that among reported cases, 72.9% involved nonfatal injuries to 59 individuals (43 cases) and 6.8% involved deaths (4 cases). The authors say newspaper reports cannot be used to estimate the total number of cases of road rage, but they can provide an early look at the phenomenon. They also warn that since "many or most" cases of road rage go unreported, their figures likely represent the tip of the iceberg. "On closer inspection, collision statistics could reveal a significant role for road rage as a cause of death and injury on Canadian roads." CMAJ 2002;167(7):761-2

Effectiveness of bike helmets

Five Canadian provinces have introduced laws mandating the use of bicycle helmets in a direct attempt to lower the incidence of bicycle-related deaths, 75% of which are due to head injury. Researchers used trained observers to identify the rates of helmet use in Halifax before, during and after 1997, when helmet legislation was introduced in Nova Scotia. The authors also looked at trends in head-injury rates during the same period. The authors found that the rate of helmet use rose from 36% in 1995 to 75% in 1997 and 84% in 1999. The proportion of injured cyclists with head injuries decreased by about half from 1995-96 to 1998-99 (1.6% v. 3.6%). CMAJ 2002;166(6):592-5

A related commentary notes that although the rate of helmet use increased after the legislation was passed, the number of cyclists declined. The author suggests combining legislation with other strategies (such as bike paths) to promote safe cycling. CMAJ 2002;166(6):602

Effectiveness of licence restrictions

A retrospective study of all Saskatchewan drivers registered from Jan. 1, 1992, to Apr. 19, 1999, indicates that restricted licensing for medical impairments can significantly decrease the rates of vehicle crashes and traffic violations. Of the 703 758 drivers in the study, researchers found that while the 23 158 with restricted licences had a higher crash rate than those without restriction, their rate was lower than that among male drivers and urban drivers. The authors also report that at-fault crash rates decreased by 12.8% and adjusted traffic violation rates decreased by 10.0% after restrictions were imposed. The authors estimate that up to 816 crashes and 751 traffic violations were averted during the study period due to licence restrictions related to medical impairments. CMAJ 2002;167(7):747-51

Off-reserve Aboriginal people face daunting health problems

Statistics Canada's 2000/01 Canadian Community Health Survey, The Health of the Off- reserve Aboriginal Population, found that natives living away from reserves are more likely to have chronic health conditions and long-term restrictions on their activity levels than their non-Aboriginal counterparts. They are also more likely to be depressed. The survey determined that 60.1% of off-reserve natives reported having at least one chronic condition, compared with 49.6% of their non-Aboriginal counterparts. The 3 most prevalent conditions were arthritis (26.4%), hypertension (15.4%) and diabetes (8.7%), with diabetes being twice as common as in the non-Aboriginal population; 23.1% of off-reserve Aboriginal people perceived their health as being only fair or poor, a rate 1.9 times higher than in the non-Aboriginal population. CMAJ 2002;167(8):912

Tough on packaging

Tough new packaging and labelling requirements for consumer products such as cleansers are expected to reduce the number of chemical-related mishaps in Canada and save the health care system about $10 million a year. The Consumer Chemicals and Containers Regulations, which were approved Oct. 1, call for leak-proof containers, more child-resistant packaging and extensive information on hazards. The old regulations were based on outdated science from the 1970s and many products weren't appropriately regulated. CMAJ 2002;166(2):228

UK restricts alcohol ads

Stung by complaints that retailers continue to market alcohol to young people, British manufacturers have proposed an advertising crackdown. The Portman Group, whose member companies produce 95% of the alcoholic drinks sold in the UK, announced that it is revising its 6-year-old marketing standards code to cover branded merchandise and promotions. According to Department of Health statistics, a majority of young Britons drink regularly by age 14 or 15, and since 1990 the amount of alcohol they consume has doubled, to 10.4 units per week. Britain's Home Office says underage drinkers find it easy to buy alcohol, with 63% of 16- and 17-year-olds and 10% of those aged 12 to 15 who drink reporting that they have been able to purchase drinks in pubs. CMAJ 2002;167(10):1157

Walkerton 2 years later

Two years after bacteria-contaminated drinking water in Walkerton, Ont., killed 7 and left more than 2300 others ill, a CMAJ correspondent interviews one of the first physicians who reported her concerns to the public health department as well as the medical officer of health who issued the first boil-water advisory for the area. CMAJ 2002;166(10):1326

A related commentary reviews Ontario's public health system and presents ideas on how it could be improved. CMAJ 2002;66(10):1282-3

TECHNOLOGY

Faulty blood pressure devices

Although automated blood pressure measuring devices are widely available for public use in pharmacies, researchers found that their accuracy doesn't measure up to the standard mercury sphygmomanometers used in doctors' offices. They conclude that reliance on the readings "could result in an inaccurate or missed diagnosis of hypertension or it could lead to an inaccurate assessment of blood pressure control in patients already receiving antihypertensive therapy." CMAJ 2002;166(10):1145-8

Usefulness of ultrasound

Researchers conducted a systematic review and meta-analysis to summarize the data from randomized controlled trails involving humans that studied the effect of ultrasound therapy on fracture healing. They found that of 138 potentially eligible studies, 3 were of good quality and sufficiently heterogeneous that the data could be pooled. These trials involved 158 fractures at 3 different sites: the tibial shaft, the distal radius and the scaphoid. In all 3 studies, the mean time to healing was shorter in the treatment group than in the control groups (weighted average effect size 6.41; 95% confidence interval 1.01-11.81). The authors acknowledge that, although more and better trials are needed, self-applied ultrasound treatment holds promise for shortening the healing time of non-operative fractures. CMAJ 2002;166(4):437-41

TOBACCO

Europe tackles tobacco epidemic

Restrictions on advertising and on smoking in public places are helping to reduce tobacco consumption in Europe, but the region still has one of the highest smoking rates in the world, the World Health Organization reports. It says smoking now causes 1.2 million deaths a year in Europe and may kill 2 million people annually by 2020. Although there have been small declines in smoking rates in some countries, smoking rates have remained steady throughout most of Western Europe, ranging from 19% in Sweden to 37% in Germany and Greece. Smoking rates are even higher in Eastern Europe, with roughly half of the men in Russia smoking. In Canada 23% of people smoke. WHO blames aggressive marketing for the fact that around 30% of 15- to 18-year-old Europeans smoke. CMAJ 2002;166(11):1456

Graphic tobacco warnings are effective

Those graphic, even grisly, warnings on Canadian cigarette packages appear to be having the desired effect, data from a Canadian Cancer Society (CCS) survey indicate. Among smokers surveyed, 43% said the warnings raised their concern about the health effects of smoking and 44% said they are now more motivated to quit. CMAJ 2002;166(11):1453

Nova Scotia tackles smoking

Nova Scotia now has province-wide anti-smoking legislation, after its legislature introduced a new law that focuses directly on children. The law, An Act to Protect Young Persons and Other Persons from Tobacco Smoke, bans smoking in most public places and workplaces, including schools, malls, taxis, theatres and recreational facilities. It will also be banned in restaurants, bars and bingo halls where youth are present, unless there is an enclosed, well-ventilated area that young people cannot enter. Anyone caught smoking in a banned area faces a fine of up to $2000. The new law, which takes effect Jan. 1, 2003, also makes it illegal for anyone under 19 to possess cigarettes. CMAJ 2002;166(12):1578

Smoking rate drops

Canadians are butting out in record numbers, with the latest data indicating that fewer than 1 in 4 Canadians now use tobacco. According to data from the Canadian Tobacco Use Monitoring Survey, 23% of Canadians — 5.7 million people aged 15 and older — were smoking in the first half of 2001, compared with 24% in 2000. This is the lowest rate since tracking began 36 years ago. In 1965, half of Canadians smoked. CMAJ 2002;166(7):947

Final data from the Canadian Tobacco Use Monitoring Survey indicates that the number of smokers continued to drop. In 2001, 22% of Canadians aged 15 and over — 5.4 million people — were smokers, compared with 24% in 2000 and 31% in 1994.

The survey, conducted by Statistics Canada on behalf of Health Canada, found that the percentage of women smokers dropped from 23% to 20% between 2000 and 2001; the percentage of men who smoke remained constant at 24%. Progress was also made among youth aged 15-19, with rates declining from 25% in 2000 to 22.5% in 2001. Adults aged 20 to 24 still have the highest smoking rate of any group, 32%, and this remained unchanged from 2000. CMAJ 2002;166(4):388

US funds study of Canada's tobacco warnings

A Canadian team has received US$275 000 from the US National Cancer Institute to support its research into whether dramatic warning labels on cigarette packaging are having an impact on high school students. Geoffrey Fong, a psychology professor at the University of Waterloo, heads the Health Behaviour Research Group that will survey 12 000 students at 9 Canadian and 6 American schools. "Labelling is one of the most important tobacco-control policies throughout the world, and our research has the potential to be useful to policy-makers in other countries," says Fong. "Canada is seen as a real leader." The Canadian labels, introduced in December 2000, include graphic pictures of diseased lungs and mouths, as well as various warnings about the adverse health effects of tobacco. CMAJ 2002;167(6):684

TRANSPLANTATION

Heart transplantation crisis

Canada's shortage of hearts for transplantation has reached crisis proportions, There was a 21% increase in the number of patients on the heart transplant waiting list in 1999, but the number of donors grew by only 6%. About half of the most desperate patients never receive the operation because of the shortage. CMAJ 2002;166(4):492

No xenotransplantation yet

Canada should not proceed with clinical trials involving the transplantation of live animal organs, tissue or cells into human patients because "critical issues" must be resolved, a Canadian Public Health Association (CPHA) report states. The majority of those consulted ... believe that too little is known about the potential risks of crossing the species barrier. CMAJ 2002;166(4):493

Organ donation in the ICU

The issue of organ donation is often revisited to ensure that, while being as effective as possible, the process is compassionate and sensitive to the needs of grieving families. Often the discussions around organ donation involve transplant procurement organizations and, in Canada, require that details of patients nearing death — which traditionally would be confidential — be reported to outside agencies. The Canadian Critical Care Society (CCCS) has produced a position paper on organ and tissue donation that outlines how the process might be improved and collaborative initiatives developed and implemented. CMAJ 2002;167(11):1248-9

Trends in transplantation

A new study finds a "significant reduction over time of RRs (rate ratios) for death and graft failure" among Canadian renal transplant patients. The authors analyzed death and graft failure rates among 11 482 Canadians with end-stage renal disease who received a kidney transplant between 1981 and 1998. They attribute the decline in mortality to refinements in patient care, and the decline in graft failures to improved immunotherapy and management of hyperlipidemia and hypertension. CMAJ 2002;167(2):137-42

Xenotransplantation

Xenotransplantation, or the transfer of living tissues or organs between species, has become a possible solution to the ever-growing demand for transplant organs, but it raises many ethical, social and health issues. In 2000, Health Canada provided funding for a series of public consultations on the issue. For over a year an advisory group travelled the country consulting with Canadians about their views. The result was a public report presented to the federal minister of health recommending that xenotransplantation clinical trials be banned for now. A commentary examines the consultation process and challenges the validity of the recommendations. CMAJ 2002;167(1):40-2

A related commentary suggests that although the consultation process was imperfect, it allowed valid public concerns to be raised about this controversial new technology. CMAJ 2002;167(1):42-3

WAR AND CONFLICT

Afghanistan's new minister of women's affairs

For more than 2 decades Dr. Sima Samar has defied Afghani laws that deny women their basic right to education and medical care. She has set up clinics and hospitals, and 21 000 children attend her schools. In December 2001, Samar accepted the John Humphrey Freedom Award from Rights & Democracy (the International Centre for Human Rights and Democratic Development) in Montreal. The $25 000 award, which she contributed to improving education Afghanistan, honours the work of social activists. That same month, Samar was appointed deputy prime minister and minister responsible for women's affairs in Afghanistan's transitional government. CMAJ 2002;166(3):368

Attacks on US a crime

World experts in peace and health have declared that the Sept. 11 attacks on US civilians should be defined as a crime, not an act of war. The declaration was made at the Peace Through Health conference at McMaster University, held a month after the terrorist attacks. It attracted 120 participants from 19 countries, and they stated that the US should respond with legal, not military, means. CMAJ 2002;166(1):78

British veterans launch suit

Military veterans who say they were not adequately treated for post-traumatic stress disorder have filed suit against the British Ministry of Defence. The case involves more than 250 former combatants who were involved in the Falklands war, policing Northern Ireland, the civil war in Bosnia, the Gulf war and other conflicts. Another 1600 veterans are considering similar action. The High Court proceedings, which began in March, focus on the experiences of 15 veterans. Suicide has claimed more British Falkland veterans than the fighting did. In all, 256 soldiers were killed during the 1982 conflict with Argentina; since than 264 veterans have committed suicide. CMAJ 2002;166(11):1453

Identifying 9/11 victims

The US Centers for Disease Control and Prevention says New York City's chief medical examiner had to issue 2734 death certificates for people killed in last year's attacks on the World Trade Center. The attacks also forced the CDC to alter its mortality-classification system. A special Sept. 11 issue of the Morbidity and Mortality Weekly Report (MMWR) stated that death certificates had been issued for 1373 people whose remains have been found and for 1361 whose remains were not found. Methods used to identify the dead included DNA screening (645), dental radiographs (188), fingerprints (71), personal effects (19) and photographs (16). Multiple methods were used to identify 407 people, while 966 were identified using a single method. The New York attacks created an unprecedented need to issue death certificates in the absence of human remains. CMAJ 2002;167(8):910

Israel criticized after Palestinian MDs killed

The deaths of 2 Palestinian physicians at the hands of Israeli soldiers have drawn strong reprimands from the Medical Network, the 120-member section of Amnesty International Canada that promotes health care workers' concerns about human rights abuses. More than half its members are physicians. CMAJ 2002;166(13):1705

MD challenges sanctions against Iraq

Dr. David Swann of Calgary was so concerned about the impact Western economic sanctions are having on Iraqi children that in March he held a 24-hour vigil outside the constituency office of his MP, Progressive Conservative leader Joe Clark. Swann is a public health physician and member of the Canadian Network to End Sanctions on Iraq. The sanctions were imposed in August 1990 after Iraq invaded Kuwait. CMAJ 2002;166(10):1319

Terrorism dominates public health

Given the shadow cast by the Sept. 11 terrorist attacks and the recent anthrax scares in the US, it is no surprise that the growing threat posed by biological weapons was the main topic when the World Medical Association (WMA) met in Washington, DC, in October. Representatives of medical associations from around the globe used the 2-day meeting to discuss how national health authorities and health professionals should deal with the possibility that diseases such as anthrax, smallpox and even influenza might be used as weapons of terror. Serious concerns were also raised that the constant focus on potential bioterrorism will push other urgent items off the public health agenda.

The bioterrorism threat has led the US to commit $1.5 billion in new funding for research in this area in 2003. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, described the spending as "quite unprecedented," calling it the "largest single increase of any discipline in any institute in the history of the [National Institutes of Health]." His institute must now decide how to spend US$1.75 billion next year on vaccines and treatments for problems such as smallpox. CMAJ 2002;167(11):1281

WOMEN'S HEALTH

Anal incontinence after childbirth

Incontinence of stool and flatus is relatively common after childbirth. To identify risk factors researchers examined characteristics and delivery details of 949 women who gave birth vaginally or by cesarean section in 1995/96; 3 months post partum the women completed a questionnaire on the frequency of anal incontinence. In total, 3.1% (29) of the women had fecal incontinence and 25.5% (242) had involuntary loss of flatus. Among the women who delivered vaginally, those with third- or fourth-degree perineal tears were almost 3 times more likely than those without anal sphincter damage to have incontinence of stool. CMAJ 2002;166(3):326-30

A related commentary discusses pelvic injury associated with vaginal birth and cesarean section and suggests that all the benefits and risks associated with both modes of delivery be considered by women and their obstetricians. CMAJ 2002;166(3):337-8

Home birth debate

Researchers compared perinatal outcomes for planned home births attended by midwives (862 births) and for planned hospital births attended by either physicians (743) or midwives (571). The authors found that more women in the home birth group than in the midwife-attended hospital group had an intact perineum (55.0% versus 44.1%). The incidence of maternal infection was lower in the home birth group than in either the physician-attended or midwife-attended hospital groups (0.7% versus 3.5%). The authors also report that neonatal outcomes included similar rates of meconium aspiration in all groups and 3 perinatal deaths (0.3%) in the home birth group, 1 (0.1%) in the physician-attended group and none in the midwife-attended hospital group. Five babies (0.6%) in the home birth group required ventilator assistance for at least 24 hours, as compared with none in either comparison group. The data suggest that there is no increased risk associated with planned midwife-attended home births, but the authors recommend ongoing evaluation of rare, but serious, adverse outcomes, including hemorrhage, death and the need for ventilator support. CMAJ 2002;166(3):315-323

A related commentary, praises the study for providing "valuable information" about the safety of home births, but also recommends close monitoring of adverse outcomes of home births in the future. CMAJ 2002;166(3):335-6

Estrogen replacement therapy

Estrogen replacement therapy is used to treat menopausal symptoms and has been found to be effective in preventing osteoporotic fractures. To investigate longitudinal trends in estrogen use by Canadian women, researchers used data from Saskatchewan Health's prescription drug plan database to calculate age-standardized prevalence rates between 1981 and 1997. The rate increased steadily, from 5.1% in 1981 to 15.4% in 1997. Estrogen use was highest among women aged 50-54, ranging from 10.8% in 1981 to 30.6% in 1997. Whether estrogen use will continue to increase in light of recent literature questioning its presumed benefits remains to be seen. CMAJ 2002;166(2):187-8

Folic acid cuts birth defect incidence

Neural tube defects (NTDs) are congenital malformations of the nervous system, such as spina bifida that occur 1 to 2 times per 1000 births. Two new studies show a significant reduction in the total incidence of open NTDs, particularly in the late 1990s. This coincided with increased efforts to promote folic acid use by encouraging women to take folic acid supplements (supplementation) and the 1998 policy to fortify flour and pasta with folic acid (fortification). Nova Scotia researchers divided the 10 years from Jan. 1, 1991, to Dec. 31, 2000, into pre-supplementation (1991-94) and postsupplementation (1995-97) and pre-fortification (1991-97) and postfortification (1998-2000) periods. The authors report that the recommendations for folic acid supplementation alone did not appear to succeed in reducing the incidence of open NTDs in Nova Scotia (2.55 per 1000 live births during 1991-94 versus 2.61 per 1000 births during 1995-97). However, the move to fortify grain products appears to have caused a significant reduction in the incidence (2.58 per 1000 births between 1991-97 versus 1.17 per 1000 births during 1998-2000). CMAJ 2002;167(2):241-5

The other study used information from the Canadian Congenital Anomalies Surveillance System and hospital data on therapeutic abortions to examine trends in the total incidence of NTDs in Ontario. The authors report an increase in the total NTD incidence rate from 1986 to 1995, which they attribute to increased prenatal screening and better detection of NTDs. However, they too report a decline in NTD incidence from 1995 to 1999. CMAJ 2002;167(2):237-40

A related commentary finds that these studies justify the fortification of foods with folic acid as an "effective and inexpensive way to ensure adequate folate levels in all prospective mothers." CMAJ 2002;167(2):255-6

Factor V Leiden and pregnancy

Pregnant women who carry the factor V Leiden mutation are predisposed to serious venous thromboembolic events. In a review article, researchers discuss the implications of factor V Leiden mutations in pregnancy, including recurrent venous thromboembolism, early onset gestational hypertension, severe placental abruption and fetal growth disturbances. They discuss approaches to the diagnosis and management of pregnant women with this genetic mutation, including the possible role of antithrombotic therapy. CMAJ 2002;167(1):48-54

HRT trial partly stopped

One part of a major trial of the risks and benefits of combined estrogen and progestin in healthy menopausal women was stopped July 9 after it was found that long-term use increases the risk of breast cancer by 26%, stroke by 41% and heart attacks by 29%. The multicentre Women's Health Initiative trial was stopped by the National Heart, Lung, and Blood Institute (NHLBI) and the National Institutes of Health. An estimated 6 million postmenopausal American women take estrogen plus progestin hormone replacement therapy. Study participants also had a statistically significant increase in coronary heart disease, stroke and pulmonary embolism. There were benefits to the combined hormone therapy, including fewer cases of hip fractures and colon cancer, but on balance the harms were greater.

The report from the WHI investigators appeared in the July 17 issue of the Journal of the American Medical Association (JAMA). The 8-year study was scheduled to run until 2005 but ended after an average follow-up of 5.2 years. The trial, involving 16 608 women age 50 to 79, was designed to examine the effect of estrogen plus progestin on the prevention of heart disease and hip fractures, and any associated change in risk for breast and colon cancer. Study participants were randomly assigned a daily dose of estrogen plus progestin, or placebo. CMAJ 2002;167(3):294

To the surprise of women and their physicians around the world, it was clear that hormone replacement therapy (HRT) with estrogen and progestin was causing significant harm. HRT has been prescribed to women for years to preserve health and prevent disease, most notably to decrease the risk of coronary artery disease and osteoporosis, and was the second most commonly prescribed medicine in the United States in 2000. Investigators describe the importance of this large, well-designed and carefully conducted study and comment on the implications for the future health of women. CMAJ 2002;167(4):357-9

A related commentary highlights the importance of randomized controlled trials in preventive medicine, with particular attention to women's health. CMAJ 2002;167(4):361-2

Another commentary weighs heavily into the often "traditional" assumptions that underlie preventive medicine. CMAJ 2002;167(4):363-4

NB, Morgentaler go to court over abortion payments

Calling New Brunswick "the most reactionary province in Canada as far as women's rights go [and] as far as access to abortion goes," Dr. Henry Morgentaler has decided to take the province to court in an attempt to force it to pay for abortions performed at his Fredericton clinic. In his Oct. 23 announcement, Morgentaler, who operates 8 abortion clinics across Canada, said New Brunswick has been "violating the law of the country by discriminating against women, by denying them access to abortion services to which they are entitled under medicare." New Brunswick pays for abortions, but only if they are judged medically necessary by 2 physicians — one must be an obstetrician/gynecologist — and performed in approved hospitals. Abortions performed in private clinics such as Morgentaler's or in facilities outside the province are not covered. CMAJ 2002;167(11):1277

Northern women at risk

One-quarter of women of child-bearing age in the Northwest Territories are "at risk" nutritionally, a Health Canada official says. Kathy Hunter, a consultant for children's programs in the Northwest Territories, says poor food selection and high costs are the main culprits. Health Canada studies indicate that the nutritional intake of these women is inadequate, particularly for key nutrients such as iron, calcium, folic acid and vitamins A, C and D. To help combat nutritional problems, the federal government is spending $230 000 to develop prenatal nutrition projects in the NWT. The goals are to improve the health of pregnant women, to encourage breast-feeding, to increase the number of babies born at ideal birth weights and to improve women's knowledge about nutrition. Two dietitians will run the program. CMAJ 2002;166(5):642

Peer support for breast-feeding

Many new mothers initiate breast-feeding but stop within weeks after delivery. Researchers conducted a randomized controlled trial to evaluate the effectiveness of peer support on prolonging the duration of breast-feeding. Recruited from semi-urban hospitals in Toronto, 256 new mothers who decided to breast-feed were randomly assigned to either regular care or to telephone-based peer support from volunteers with breast-feeding experience. Follow-up at 4, 8 and 12 weeks post partum showed consistently higher rates of breast-feeding in the peer support group than in the usual care group (92.4% versus 83.9% at 4 weeks, 84.8% versus 75.0% at 8 weeks and 81.1% versus 66.9% at 12 weeks). CMAJ 2002;166(1):21-8

A related commentary applauds the study for supplying "the needed evidence that indeed peer support does make a difference in the long-term outcome of breast-feeding." The author notes that further study is needed to verify whether the differences would persist beyond 3 months post partum. CMAJ 2002;166(1):42-3

The birth of a new idea

Conventional wisdom #151; based primarily on surgical practices — holds that the more times a physician completes a procedure, the better the outcome will be. However, in a study of all single births attended primarily by family physicians at a Vancouver teaching hospital, researchers found no association between adverse outcomes for mothers or newborns and family physicians who make few deliveries. The Society of Obstetricians and Gynaecologists of Canada and the College of Family Physicians of Canada, which had both maintained that attending a minimum of 24 births per year was required to maintain competence, have changed their position because of this study and other new evidence. CMAJ 2002;166(10):1257-63