Showing papers in "Canadian Medical Association Journal in 2001"

Homelessness and health

Abstract: Homelessness affects tens of thousands of canadians and has important health implications. Homeless people are at increased risk of dying prematurely and suffer from a wide range of health problems, including seizures, chronic obstructive pulmonary disease, musculoskeletal disorders, tuberculosis, and skin and foot problems. Homeless people also face significant barriers that impair their access to health care. More research is needed to identify better ways to deliver care to this population.

Assessing telemedicine: a systematic review of the literature

Abstract: Background: To clarify the current status of telemedicine, we carried out a systematic review of the literature. We identified controlled assessment studies of telemedicine that reported patient outcomes, administrative changes or economic assessments and assessed the quality of that literature. Methods: We carried out a systematic electronic search for articles published from 1966 to early 2000 using the MEDLINE (1966–April 2000), HEALTHSTAR (1975–January 2000), EMBASE (1988–February 2000) and CINALH (1982–January 2000) databases. In addition, the HSTAT database (Health Services/Technology Assessment Text, US National Library of Medicine), the Database of Abstracts of Reviews of Effectiveness (DARE, NHS Centre for Reviews and Dissemination, United Kingdom), the NHS Economic Evaluation Database and the Cochrane Controlled Trials Register were searched. We consulted experts in the field and did a manual search of the reference lists of review articles. Results: A total of 1124 studies were identified. Based on a review of the abstracts, 133 full-text articles were obtained for closer inspection. Of these, 50 were deemed to represent assessment studies fulfilling the inclusion criteria of the review. Thirty-four of the articles assessed at least some clinical outcomes; the remaining 16 were mainly economic analyses. Most of the available literature referred only to pilot projects and short-term outcomes, and most of the studies were of low quality. Relatively convincing evidence of effectiveness was found only for teleradiology, teleneurosurgery, telepsychiatry, transmission of echocardiographic images, and the use of electronic referrals enabling email consultations and video conferencing between primary and secondary health care providers. Economic analyses suggested that teleradiology, especially transmission of CT images, can be cost-saving. Interpretation: Evidence regarding the effectiveness or cost-effectiveness of telemedicine is still limited. Based on current scientific evidence, only a few telemedicine applications can be recommended for broader use.

The pharmacology and toxicology of “ecstasy” (MDMA) and related drugs

Abstract: "Ecstasy" (MDMA) and related drugs are amphetamine derivatives that also have some of the pharmacological properties of mescaline. They have become popular with participants in "raves," because they enhance energy, endurance, sociability and sexual arousal. This vogue among teenagers and young adults, together with the widespread belief that "ecstasy" is a safe drug, has led to a thriving illicit traffic in it. But these drugs also have serious toxic effects, both acute and chronic, that resemble those previously seen with other amphetamines and are caused by an excess of the same sympathomimetic actions for which the drugs are valued by the users. Neurotoxicity to the serotonergic system in the brain can also cause permanent physical and psychiatric problems. A detailed review of the literature has revealed over 87 "ecstasy"-related fatalities, caused by hyperpyrexia, rhabdomyolysis, intravascular coagulopathy, hepatic necrosis, cardiac arrhythmias, cerebrovascular accidents, and drug-related accidents or suicide. The toxic or even fatal dose range overlaps the range of recreational dosage. The available evidence does not yet permit an accurate assessment of the size of the problem presented by the use of these drugs.

Intention-to-treat principle

Abstract: In deciding if a treatment is likely to work in an individual patient, clinicians need to know the effect of the intervention in patients who take the treatment as prescribed. However, participants in clinical trials may not adhere to the protocol, or clinicians may recommend withdrawal of the study

Cervical cancer: epidemiology, prevention and the role of human papillomavirus infection

Abstract: ORGANIZED SCREENING HAS CONTRIBUTED TO A DECLINE in cervical cancer incidence and mortality over the past 50 years. However, women in developing countries are yet to profit extensively from the benefits of screening programs, and recent trends show a resurgence of the disease in developed countries. The past 2 decades have witnessed substantial progress in our understanding of the natural history of cervical cancer and in major treatment advances. Human papillomavirus (HPV) infection is now recognized as the main cause of cervical cancer, the role of coexisting factors is better understood, a new cytology reporting terminology has improved diagnosis and management of precursor lesions, and specific treatment protocols have increased survival among patients with early or advanced disease. Current research has focused on the determinants of infection with oncogenic HPV types, the assessment of prophylactic and therapeutic vaccines and the development of screening strategies incorporating HPV testing and other methods as adjunct to cytology. These are fundamental stepping stones for the implementation of effective public health programs aimed at the control of cervical cancer.

Does how you do depend on how you think you'll do? A systematic review of the evidence for a relation between patients' recovery expectations and health outcomes

Abstract: Background: Most clinicians would probably agree that what patients think will happen can influence what does happen over the clinical course. Yet despite useful narrative reviews on expectancy of therapeutic gain >and the mechanisms by which expectancy can affect health outcomes, we were unable to locate a systematic review of the predictive relation between patients9 recovery expectations and their health outcomes. Methods: We searched MEDLINE for English-language articles published from 1966 to June 1998 with a title or abstract containing at least 1 of the medical subject headings (MeSH) “self-assessment,” “self-concept” or “attitude to health,” or the MeSH subheading “psychology,” and at least 1 word from each of 3 sets: “patient” and similar words; a form of “expectation,” “belief” or “prediction”; and a form of “recover,” “outcome,” “survival” or “improve.” Relevant articles contained original research data, measured patients9 recovery expectations, independently measured a subsequent health outcome and analyzed the relation between expectations and outcomes. We assessed internal validity using quality criteria for prognostic studies based on 6 categories (case definition; patient selection; extent of follow-up; objective outcome criteria; measurement and reporting of recovery expectations; and analysis). Results: A total of 1243 titles or abstracts were identified through the computer search, and 93 full-text articles were retrieved. Forty-one of these articles met the relevance criteria, along with 4 additional articles identified through other means. Agreement beyond chance on quality assessments of 18 randomly selected articles was high (kappa = 0.87, p = 0.001). Sixteen of the 45 articles provided moderate-quality evidence and included a range of clinical conditions and study designs; 15 of the 16 showed that positive expectations were associated with better health outcomes. The strength of the relation depended on the clinical conditions and the measures used. Interpretation: Consistency across the studies reviewed and the evidence they provided support the need for clinicians to clarify patients9 expectations and to assist them in having appropriate expectations of recovery. The understanding of the nature, extent and clinical implications of the relation between expectations and outcomes could be enhanced by more conceptually driven and methodologically sound research, including evaluations of intervention effectiveness.

How efficacious and safe is short-acting methylphenidate for the treatment of attention-deficit disorder in children and adolescents? A meta-analysis

Abstract: Background: Numerous small clinical trials have been carried out to study the behaviourally defined efficacy and safety of short-acting methylphenidate compared with placebo for attention-deficit disorder (ADD) in individuals aged 18 years and less. However, no meta-analyses that carefully examined these questions have been done. We reviewed the behavioural evidence from all the randomized controlled trials that compared methylphenidate and placebo, and completed a meta-analysis. Methods: We searched several electronic sources for articles published between 1981 and 1999: MEDLINE, EMBASE, PsychINFO, ERIC, CINAHL, HEALTHSTAR, Biological Abstracts, Current Contents and Dissertation Abstracts. The Cochrane Library Trials Registry and Current Controlled Trials were also consulted. A study was considered eligible for inclusion if it entailed the following: a placebo- controlled randomized trial that involved short-acting methylphenidate and participants aged 18 years or less at the start of the trial who had received any primary diagnosis of ADD that was made in a systematic and reproducible way. Results: We included 62 randomized trials that involved a total of 2897 participants with a primary diagnosis of ADD (e.g., with or without hyperactivity). The median age of trial participants was 8.7 years, and the median “percent male” composition of trials was 88.1%. Most studies used a crossover design. Using the scores from 2 separate indices, this collection of trials exhibited low quality. Interventions lasted, on average, 3 weeks, with no trial lasting longer than 28 weeks. Each primary outcome (hyperactivity index) demonstrated a significant effect of methylphenidate (effect size reported by teacher 0.78, 95% confidence interval [CI] 0.64–0.91; effect size reported by parent 0.54, 95% CI 0.40–0.67). However, these apparent beneficial effects are tempered by a strong indication of publication bias and the lack of robustness of the findings, especially those involving core ADD features. Methylphenidate also has an adverse event profile that requires consideration. For example, clinicians only need to treat 4 children to identify an episode of decreased appetite. Interpretation: Short-acting methylphenidate has a statistically significant clinical effect in the short-term treatment of individuals with a diagnosis of ADD aged 18 years and less. However, the extension of this placebo-controlled effect beyond 4 weeks of treatment has not been demonstrated. Exact knowledge of the extent and definition of the short-term behavioural usefulness of methylphenidate is questioned.

Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study

Abstract: Background: Delirium in older hospital inpatients appears to be associated with various adverse outcomes. The limitations of previous research on this association have included small sample sizes, short follow-up periods and lack of consideration of important confounders or modifiers, such as severity of illness, comorbidity and dementia. The objective of this study was to determine the prognostic significance of delirium, with or without dementia, for cognitive and functional status during the 12 months after hospital admission, independent of premorbid function, comorbidity, severity of illness and other potentially confounding variables. Methods: Patients 65 years of age and older who were admitted from the emergency department to the medical services were screened for delirium during their first week in hospital. Two cohorts were enrolled: patients with prevalent or incident delirium and patients without delirium, but similar in age and cognitive impairment. The patients were followed up at 2, 6 and 12 months after hospital admission. Analyses were conducted for 4 patient groups: 56 with delirium, 53 with dementia, 164 with both conditions and 42 with neither. Baseline measures included delirium (Confusion Assessment Method), dementia (Informant Questionnaire on Cognitive Decline in the Elderly), physical function (Barthel Index [BI] and premorbid instrumental activities of daily living, IADL), the Mini-Mental State Examination (MMSE), comorbidity, and physiologic and clinical severity of illness. Outcome variables measured at follow-up were the MMSE, Barthel Index, IADL and admission to a long-term care facility. Results: After adjustment for covariates, the mean differences in MMSE scores at follow-up between patients with and without delirium were –4.99 (95% confidence interval [CI] –7.17 to –2.81) for patients with dementia and –3.36 (95% CI –6.15 to –0.58) for those without dementia. At 12 months, the adjusted mean differences in the BI were –16.45 (95% CI –27.42 to –5.50) and –13.89 (95% CI –28.39 to 0.61) for patients with and without dementia respectively. Patients with both delirium and dementia were more likely to be admitted to long-term care than those with neither condition (adjusted odds ratio 3.18, 95% CI 1.19 to 8.49). Dementia but not delirium predicted worse IADL scores at follow-up. Unadjusted analyses yielded similar results. Interpretation: For older patients with and without dementia, delirium is an independent predictor of sustained poor cognitive and functional status during the year after a medical admission to hospital.

Abuse: A risk factor for low birth weight? A systematic review and meta-analysis

Abstract: Background: Abuse during pregnancy is considered to be a potentially modifiable risk factor for low birth weight (LBW). We conducted a systematic review and meta-analysis to determine the strength of association between physical, sexual or emotional abuse during pregnancy and LBW. Methods: We selected papers for review from an electronic search of MEDLINE (1966–1999), CINAHL (1982–1997) and the Cochrane Library. We retrieved articles using the following MeSH headings and keywords: “infant low birth weight,” “fetus,” “perinatal care,” “pregnancy,” “prenatal care,” “infant mortality,” “violence,” “battered women,” “spouse abuse,” “infant morbidity,” “antenatal” and “neonatal.” When necessary, we contacted authors to obtain data that were not included in the published material. We analyzed the methodological quality of each eligible study and selected those of the highest quality for meta-analysis. Results: We reviewed 14 studies, of which 8 were selected for meta-analysis. Using a fixed-effects model, we found that women who reported physical, sexual or emotional abuse during pregnancy were more likely than nonabused women to give birth to a baby with LBW (odds ratio 1.4, 95% confidence interval 1.1–1.8). Interpretation: Abuse may be part of a complex interaction of factors that contribute to LBW.

Disordered eating attitudes and behaviours in teenaged girls: a school-based study

Abstract: Background: Disordered eating attitudes and behaviours are common in older teens and young women in Western countries. Recent evidence suggests that the prevalence of these disorders is rising and that the age of onset has fallen. In the present study, disturbed eating attitudes and behaviours were evaluated in a large school-based population in Ontario in order to determine their prevalence and demographic distribution. Methods: Females, aged 12–18 years, from schools in Toronto, Hamilton and Ottawa were invited to complete questionnaires, including 3 subscales of the Eating Disorder Inventory (Drive for Thinness, Body Dissatisfaction, Bulimia), the Eating Attitudes Test-26 (EAT-26) and the Diagnostic Survey for Eating Disorders (DSED). Results: Questionnaires were completed by 1739 (70%) of the 2483 adolescent females who were approached. The mean age of subjects in the sample was 14.6 (standard deviation 1.9) years. Thirteen percent of those aged 12–14 years and 16% of those aged 15–18 years had scores above the recommended cut-off (≥ 20) for disordered eating on the EAT-26. Current dieting to lose weight was reported by 23% of participants. Binge eating with associated loss of control was reported by 15% of participants, self-induced vomiting by 8.2% and the use of diet pills by 2.4%. Laxative and diuretic misuse were uncommon. Dieting was associated with an increased risk of binge-eating and purging behaviours. Older age and body mass index in the highest quartile were independently related to symptoms of eating disorders. Interpretation: Disordered eating attitudes and behaviours were present in over 27% of girls aged 12–18 years and were seen to increase gradually throughout adolescence. Prevention programs to diminish the progression and impact of these disorders should be implemented and assessed.

Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema

Abstract: Objective: To provide information and recommendations for women and their physicians when making decisions about the management of lymphedema related to breast cancer. Options: Compression garments, pneumatic compression pumps, massage and physical therapies, other physical therapy modalities, pharmaceutical treatments. Outcomes: Symptom control, quality of life, cosmetic results. Evidence: Systematic review of English-language literature retrieved primarily from MEDLINE (1966 to April 2000) and CANCERLIT (1985 to April 2000). Nonsystematic review of breast cancer literature published to October 2000. Recommendations: • Pre- and postoperative measurements of both arms are useful in the assessment and diagnosis of lymphedema. Circumferential measurements should be taken at 4 points: the metacarpal‐phalangeal joints, the wrists, 10 cm distal to the lateral epicondyles and 15 cm proximal to the lateral epicondyles. • Clinicians should elicit symptoms of heaviness, tightness or swelling in the affected arm. A difference of more than 2.0 cm at any of the 4 measurement points may warrant treatment of the lymphedema, provided that tumour involvement of the axilla or brachial plexus, infection and axillary vein thrombosis have been ruled out. • Practitioners may want to encourage long-term and consistent use of compression garments by women with lymphedema. • One randomized trial has demonstrated a trend in favour of pneumatic compression pumps compared with no treatment. Further randomized trials are required to determine whether pneumatic compression provides additional benefit over compression garments alone. • Complex physical therapy, also called complex decongestive physiotherapy, requires further evaluation in randomized trials. In one randomized trial no difference in outcomes was detected between compression garments plus manual lymph drainage versus compression garments alone. • Clinical experience supports encouraging patients to consider some practical advice regarding skin care, exercise and body weight. [A patient version of these guidelines appears in Appendix 2.] Validation: An initial draft of this document was developed by a task force sponsored by the BC Cancer Agency. It was updated and revised substantially by a writing committee and then submitted for further review, revision and approval by the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Sponsor: The steering committee was convened by Health Canada.

Hospital utilization and costs in a cohort of injection drug users

Abstract: Background: Many injection drug users (IDUs) seek care at emergency departments and some require hospital admission because of late presentation in the course of their illness. We determined the predictors of frequent emergency department visits and hospital admissions among community-based IDUs and estimated the incremental hospital utilization costs incurred by IDUs with early HIV infection relative to costs incurred by HIV-negative IDUs. Methods: The Vancouver Injection Drug User Study (VIDUS) is a prospective cohort study involving IDUs that began in 1996. Our analyses were restricted to the 598 participants who gave informed consent for our study. We used the participants’ responses to the baseline VIDUS questionnaire and, from medical records at St. Paul’s Hospital, Vancouver, we collected detailed information about the frequency of emergency department visits, hospital admissions and the primary diagnosis for all visits or hospital stays between May 1, 1996, and Aug. 31, 1999. The incremental difference in hospital utilization costs by HIV status was estimated, based on 105 admissions in a subgroup of 64 participants. Results: A total of 440 (73.6%) of the 598 IDUs made 2763 visits to the emergency department at St. Paul’s Hospital during the study period. Of these 440, 265 (60.2%) made frequent visits (3 or more). The following factors were associated with frequent use: HIV-positive status (seroprevalent: adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.2–2.6; seroconverted during study period: adjusted OR 3.0, 95% CI 1.6–5.7); more than 4 injections daily (adjusted OR 1.5, 95% CI 1.1–2.1); cocaine use more frequent than use of other drugs (adjusted OR 2.0, 95% CI 1.2–3.6); and unstable housing (adjusted OR 1.5, 95% CI 1.1–2.2). During the study period 210 of the participants were admitted to hospital 495 times; 118 (56.2%) of them were admitted frequently (2 or more admissions). The 2 most common reasons for admission were pneumonia (132 admissions among 79 patients) and soft-tissue infections (cellulitis and skin abscess) (90 admissions among 59 patients). The following factors were independently associated with frequent hospital admissions: HIV-positive status (seroprevalent: adjusted OR 5.4, 95% CI 3.4–8.6; seroconverted during study period: adjusted OR 2.9, 95% CI 1.4–6.0); and female sex (adjusted OR 1.8, 95% CI 1.1–3.1). The incremental hospital utilization costs incurred by HIV-positive IDUs relative to the costs incurred by HIV-negative IDUs were $1752 per year. Interpretation: Hospital utilization was significantly higher among communitybased IDUs with early HIV disease than among those who were HIV negative. Much of the hospital use was related to complications of injection drug use and may be reduced with the establishment of programs that integrate harm reduction strategies with primary care and addiction treatment.

Preventive health care, 2001 update: Should women be routinely taught breast self-examination to screen for breast cancer?

Abstract: Objectives: To evaluate the evidence relating to the effectiveness of breast selfexamination (BSE) to screen for breast cancer and to provide recommendations for routine teaching of BSE to women in various age groups as part of a periodic health examination. Options: Routine teaching of BSE to women. Evidence: The electronic databases MEDLINE, PreMEDLINE, CINAHL, HealthSTAR, Current Contents and the Cochrane Library were searched for abstracts and full reports of studies published from 1966 to October 2000 that evaluated the effectiveness of BSE in reducing breast cancer mortality. In addition, references of key papers were searched and experts consulted to ensure that all relevant articles had been identified. Outcomes: Prevention of death from breast cancer was viewed as the most important outcome; other outcomes examined included the stage of cancer detected, the rate of benign biopsy results, the number of patient visits for breast complaints, and psychological benefits and harms. Values: The recommendations of this report reflect the commitment of the Canadian Task Force on Preventive Health Care to provide a structured, evidencebased appraisal of whether a manoeuvre should be included in the periodic health examination. Benefits, harms and costs: Breast cancer is the most frequently diagnosed cancer among Canadian women, accounting for 30% of all new cancer cases each year. In 2000 an estimated 19 200 Canadian women would have been diagnosed with breast cancer, and 5500 would have died from the disease. To date, 2 large randomized controlled trials, a quasi-randomized trial, a large cohort study and several case‐control studies have failed to show a benefit for regular performance of BSE or BSE education, compared with no BSE. In contrast, there is good evidence of harm from BSE instruction, including significant increases in the number of physician visits for the evaluation of benign breast lesions and significantly higher rates of benign biopsy results. Recommendations:

Unsafe injection practices in a cohort of injection drug users in Vancouver: Could safer injecting rooms help?

Abstract: Background: In several European countries safer injecting rooms have reduced the public disorder and health-related problems of injection drug use. We explored factors associated with needle-sharing practices that could potentially be alleviated by the availability of safer injecting rooms in Canada. Methods: The Vancouver Injection Drug User Study is a prospective cohort study of injection drug users (IDUs) that began in 1996. The analyses reported here were restricted to the 776 participants who reported actively injecting drugs in the 6 months before the most recent follow-up visit, during the period January 1999 to October 2000. Needle sharing was defined as either borrowing or lending a used needle in the 6-month period. Results: Overall, 214 (27.6%) of the participants reported sharing needles during the 6 months before follow-up; 106 (13.7%) injected drugs in public, and 581 (74.9%) reported injecting alone at least once. Variables independently associated with needle sharing in a multivariate analysis included difficulty getting sterile needles (adjusted odds ratio [OR] 2.7, 95% confidence interval [CI] 1.8–4.1), requiring help to inject drugs (adjusted OR 2.0, 95% CI 1.4–2.8), needle reuse (adjusted OR 1.8, 95% CI 1.3–2.6), frequent cocaine injection (adjusted OR 1.6, 95% CI 1.1–2.3) and frequent heroin injection (adjusted OR 1.5, 95% CI 1.04–2.1). Conversely, HIV-positive participants were less likely to share needles (adjusted OR 0.5, 95% CI 0.4–0.8), although 20.2% of the HIVpositive IDUs still reported sharing needles. Interpretation: Despite the availability of a large needle-exchange program and targeted law enforcement efforts in Vancouver, needle sharing remains an alarmingly common practice in our cohort. We identified a number of risk behaviours — difficulty getting sterile needles, needle sharing and reuse, injection of drugs in public and injecting alone (one of the main contributing causes of overdosing) — that may be alleviated by the establishment of supervised safer injecting rooms.

Informed and shared decision-making: the crux of patient-centred care

Abstract: Thirty-five years ago, when I was a medical student, we were taught to be paternalistic. We were trained to withhold information from patients, especially painful information about a potentially terminal illness; we were also instructed to take charge of interviews and to avoid getting “

Incidence of hepatitis C virus infection among injection drug users during an outbreak of HIV infection

Abstract: Background: Beginning in 1994, Vancouver experienced an explosive outbreak of HIV infection among injection drug users (IDUs). The objectives of this study were to measure the prevalence and incidence of hepatitis C virus (HCV) infection in this context and to examine factors associated with HCV seroconversion among IDUs. Methods: IDUs recruited through a study site and street outreach completed interviewer-administered questionnaires covering subjects’ characteristics, behaviour, health status and service utilization and underwent serologic testing for HIV and HCV at baseline and semiannually thereafter. A Cox proportional hazards model was used to identify independent correlates of HCV seroconversion. Results: As of Nov. 30, 1999, 1345 subjects had been recruited into the study cohort. The prevalence of anti-HCV antibodies was 81.6% (95% confidence interval [CI] 79.6% to 83.6%) at enrolment. Sixty-two HCV seroconversions occurred among 155 IDUs who were initially HCV negative and who returned for followup, for an overall incidence density rate of 29.1 per 100 person-years (95% CI 22.3 to 37.3). The HCV incidence remained above 16 per 100 person-years over 3 years of observation (December 1996 to November 1999), whereas HIV incidence declined from more than 19 to less than 5 per 100 person-years. Independent correlates of HCV seroconversion included female sex, cocaine use, injecting at least daily and frequent attendance at a needle exchange program. Interpretation: Because of high transmissibility of HCV among those injecting frequently and using cocaine, the harm reduction initiatives deployed in Vancouver during the study period proved insufficient to eliminate hepatitis C transmission in this population.

Preventive health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns.

Abstract: Objective: To review the effectiveness of, and make practice recommendations for, serial clinical examination and ultrasound screening for developmental dysplasia of the hip (DDH) in newborns. The effectiveness of selective screening of high-risk infants with hip and pelvic radiographs and treatment with abduction therapy are also examined. Options: Screening: serial clinical examination, ultrasound screening, radiographic evaluation. Treatment: abduction therapy. Outcomes: Rates of operative intervention, abduction splinting, delayed diagnosis of DDH (beyond 3–6 months), treatment complications and false diagnostic labelling. Long-term functional outcomes were considered important. Evidence: MEDLINE was searched for relevant English-language articles published from 1966 to November 2000 using the key words “screening,” “hip,” “dislocation,” “dysplasia,” “congenital” and “ultrasound.” Comparative and descriptive studies and key reviews were retrieved, and their bibliographies were manually searched for further studies. Benefits, harms and costs: Because most infants will have spontaneous resolution of nonteratologic DDH, early identification and intervention results in unnecessary labelling of newborns as having the problem and unnecessary treatment. Ultrasound screening is a highly sensitive but poorly specific measure of clinically relevant DDH. Abduction splinting is associated with a variety of problems, and its effectiveness in treating DDH is not clearly known. At least 20% of infants requiring operative intervention have had splint therapy. The harms of labelling, repetitive investigations, unnecessary splinting and resource consumption associated with screening are substantial. Values: The strength of evidence was evaluated using the evidence-based methods of the Canadian Task Force on Preventive Health Care. Recommendations: · There is fair evidence to include serial clinical examination of the hips by a trained clinician in the periodic health examination of all infants until they are walking independently (level II-1 and III evidence; grade B recommendation).· There is fair evidence to exclude general ultrasound screening for DDH from the periodic health examination of infants (level II-1 and III evidence; grade D recommendation).· There is fair evidence to exclude selective screening for DDH from the periodic health examination of high-risk infants (level II-1 and III evidence; grade D recommendation).· There is fair evidence to exclude routine radiographic screening for DDH from the periodic health examination of high-risk infants (level III evidence; grade D recommendation).· There is insufficient evidence to evaluate the effectiveness of abduction therapy (level III evidence; grade C recommendation), but good evidence to support a period of close observation for newborns with clinically detected DDH (level I evidence; grade A recommendation). However, there is insufficient evidence to determine the optimal duration of observation (level III evidence; grade C recommendation). Validation: The members of the Canadian Task Force on Preventive Health Care reviewed the findings of this analysis through an iterative process. The task force sent the final review and recommendations to selected external expert reviewers, and their feedback was incorporated in the final draft of the manuscript. Sponsors: The Canadian Task Force on Preventive Health Care is funded through a partnership between the Provincial and Territorial Ministries of Health and Health Canada.

Medical and nonmedical stimulant use among adolescents: from sanctioned to unsanctioned use

Abstract: Background: The past decade has seen a generalized upward trend in the prevalence of adolescent use of substances, including stimulants. The purpose of this article was to determine the prevalence of and risk factors for the medical and nonmedical use of stimulants, and the diversion of prescribed stimulants among adolescent students, and to demonstrate links between medical use, nonmedical use and the diversion of stimulants. Methods: A self-reported anonymous questionnaire was administered in 1998 to a random sample of students in grades 7, 9, 10 and 12 in New Brunswick, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador about their medical and nonmedical use of stimulants (Benzedrine, Dexedrine, Ritalin, Cylert, diet pills, “speed,” “uppers,” “bennies” and “pep pills”). A total of 13 549 students completed the questionnaire, representing a 99% participation rate among the students present at school on the day of the survey. Results: Of the 5.3% of students who reported medical use of stimulants in the 12 months before the survey, 14.7% reported having given some of their medication, 7.3% having sold some of their medication, 4.3% having experienced theft and 3.0% having been forced to give up some of their medication. Nonmedical stimulant use by students who did not have a prescription for stimulants was significantly related to increased numbers of students who gave or sold some of their prescribed stimulants, at both the school class and individual student levels ( p Interpretation: Although the vast majority of adolescent students taking prescribed stimulants appeared to be using their medication as sanctioned, a link was found between medical and nonmedical stimulant use and the diversion of medication from sanctioned to unsanctioned use.

New insights into the physiology and pharmacology of vitamin C

Abstract: Pharmacokinetic data are now available for the absorption, plasma concentrations and renal excretion of vitamin C. With these new insights, it is worth reconsidering the clinical role of vitamin C in scurvy and subclinical deficiency, the amount of vitamin C required for good health and, in

Risk factors for hepatitis C virus infection among street youths

Abstract: Background: The relative contributions to risk of hepatitis C virus (HCV) infection resulting from unsafe sexual behaviours and exposures to blood (e.g., tattooing, body piercing and injection drug use) among youths at risk are not well known. We interviewed street youths about risk factors for HCV infection and documented their HCV antibody status. Methods: From December 1995 to September 1996 we recruited 437 youths aged 14 to 25 years who met specific criteria for itinerancy. Data on sociodemographic characteristics and lifetime risk factors were obtained during a structured interview, and a venous blood sample was taken for HCV antibody testing. Results: Many of the subjects reported behaviours that put them at risk for bloodborne diseases: 45.8% had injected drugs, 56.5% had at least 1 tattoo, and 78.3% had body piercing. The overall prevalence of HCV infection was 12.6% (95% confidence interval [CI] 9.7%–15.9%). In a multivariate logistic regression analysis, injecting drugs (adjusted odds ratio [OR] 28.4 [95% CI 6.6–121.4]), being over 18 years of age (adjusted OR 3.3 [95% CI 1.6–7.0]) and using crack cocaine (adjusted OR 2.3 [95% CI 1.0–5.3]) were independent risk factors for HCV infection. Having more than 1 tattoo (adjusted OR 1.8 [95% CI 0.95–3.6]) was marginally associated with HCV infection, and body piercing was not. Interpretation: Drug injection was the factor most strongly associated with HCV infection among street youths. Given that injection drug users are the driving force of the HCV infection epidemic in Canada, increased intervention efforts to prevent initiation of drug injection are urgently needed to curb the epidemic.

Bioethics for clinicians: 23. Disclosure of medical error

Abstract: ADVERSE EVENTS AND MEDICAL ERRORS ARE NOT UNCOMMON. In this article we review the literature on such events and discuss the ethical, legal and practical aspects of whether and how they should be disclosed to patients. Ethics, professional policy and the law, as well as the relevant empirical literature, suggest that timely and candid disclosure should be standard practice. Candour about error may lessen, rather than increase, the medicolegal liability of the health care professionals and may help to alleviate the patient’s concerns. Guidelines for disclosure to patients, and their families if necessary, are proposed.

Predictors of mammography use among Canadian women aged 50–69: findings from the 1996/97 National Population Health Survey

Abstract: Background: Screening mammography, although recommended every 2 years for women aged 50‐69, is thought to be underused among select groups of Canadian women. Methods: We used data from the 1996/97 National Population Health Survey to describe current patterns in mammography use (including reasons for not having a mammogram within the 2 years before the survey and future screening intentions) in Canada and to determine factors associated with nonparticipation and time-inappropriate use (mammogram 2 or more years before the survey) among women aged 50‐69. Results: Among respondents aged 50‐69, 79.1% (95% confidence interval [CI] 76.9%‐81.2%) reported ever having had a mammogram, and 53.6% (95% CI 51.4%‐55.9%) had had a recent (time-appropriate) mammogram (within the 2 years before the survey). Only 0.6% (95% CI 0.3%‐0.9%) of recently screened women reported problems of access, and few reported personal or health system barriers as reasons for not obtaining a recent mammogram. Over 50% of the women who had not had a recent mammogram reported that they did not think it was necessary, and only 28.2% (95% CI 23.8%‐32.7%) of those who had never had a mammogram planned to have one within the 2 years following the survey. The rate of time-appropriate mammography varied significantly by province, from 41.1% (95% CI 29.3%‐52.9%) in Newfoundland to 69.4% (95% CI 61.3%‐77.6%) in British Columbia. Significant predictors of never having had a mammogram included higher age, residence in a rural area, Asia as place of birth, no involvement in volunteer groups, no regular physician or recent medical consultations (including recent blood pressure check), current smoking, infrequent physical activity and no hormone replacement therapy. Interpretation: Despite increases in mammography screening rates since the 1994/95 National Population Health Survey, current estimates indicate that almost 50% of women aged 50‐69 have not had a time-appropriate mammogram. Our findings confirm continued low mammography participation rates among older women and those in rural areas, select ethnic groups and women with negative health care and lifestyle characteristics.

The evolution of methicillin-resistant Staphylococcus aureus in Canadian hospitals: 5 years of national surveillance.

Abstract: Background: To better understand the epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) in Canadian hospitals, surveillance has been conducted in sentinel hospitals across the country since 1995. We report the results of the first 5 years of the program. Methods: For each newly identified inpatient with MRSA, medical records were reviewed for demographic and clinical data. Isolates were subjected to susceptibility testing and molecular typing by pulsed-field gel electrophoresis. Results: A total of 4507 patients infected or colonized with MRSA were identified between January 1995 and December 1999. The rate of MRSA increased each year from a mean of 0.95 per 100 S. aureus isolates in 1995 to 5.97 per 100 isolates in 1999 (0.46 per 1000 admissions in 1995 to 4.12 per 1000 admissions in 1999) (p < 0.05). Most of the increase in MRSA occurred in Ontario, Quebec and the western provinces. Of the 3009 cases for which the site of MRSA acquisition could be determined, 86% were acquired in a hospital, 8% were acquired in a long-term care facility and 6% were acquired in the community. A total of 1603 patients (36%) were infected with MRSA. The most common sites of infection were skin or soft tissue (25% of MRSA infections), pulmonary tissues (24%) and surgical sites (23%); 13% of the patients were bacteremic. An epidemiologic link with a previously identified MRSA patient was suspected in 53% of the cases. Molecular typing indicated that most (81%) of the isolates could be classified as related to 1 of the 4 Canadian epidemic strains of MRSA. Interpretation: There has been a significant increase in the rate of isolating MRSA in many Canadian hospitals, related to the transmission of a relatively small number of MRSA strains.

Double trouble: impact of inappropriate use of asthma medication on the use of health care resources.

Abstract: Background: There is considerable controversy about the regular use of short- acting β-agonists for the treatment of asthma. Although case–control studies have suggested that excessive use of these drugs may worsen asthma control and increase the risk of fatal or near-fatal asthma, the controversy remains unresolved because of the confounding that exists among disease control, disease severity and the use of short-acting β-agonists. Whatever the cause-and-effect relation between the use of short-acting β-agonists and disease severity, we hypothesized that their excessive use, in conjunction with underuse of inhaled corticosteroids, would be a marker for poorly controlled asthma and excessive use of health care resources. Methods: To characterize the pattern of health services utilization among asthmatic patients taking various doses of inhaled β-agonists and corticosteroids in British Columbia, we linked the relevant health administrative databases. All patients between 5 and 50 years of age for whom a prescription for a short-acting β-agonist was filled in 1995 and whose prescription data were captured through the provincial drug plan were included in a retrospective analysis of prescriptions for asthma drugs, physician prescribing patterns and health services utilization. Patients9 use of asthma medication was classified as appropriate (low doses of short-acting β-agonist and high doses of inhaled corticosteroid) or inappropriate (high doses of short-acting β-agonist and low doses of inhaled corticosteroid), and the 2 resulting groups were compared, by means of logistic, Poisson and gamma regression, for differences in prescribing patterns, physician visits and use of hospital resources. Results: A total of 23 986 patients were identified as having filled a prescription for a short-acting β-agonist (for inhalation) in 1995. Of these, 3069 (12.8%) filled prescriptions for 9 or more canisters of β-agonist, and of this group of high-dose β-agonist users, 763 (24.9%) used no more than 100 μg/day of inhaled beclomethasone. On average, those with inappropriate use of β-agonists visited significantly more physicians for their prescriptions (1.8 v. 1.4), and each of these physicians on average wrote significantly more prescriptions for asthma medications per patient than the physicians who prescribed to appropriate users (5.2 v. 2.5 prescriptions). Patients with inappropriate use were more likely to be admitted to hospital (adjusted relative risk [RR] 1.68, 95% confidence interval [CI] 1.25–2.26), were admitted to hospital more frequently (adjusted RR 1.81, 95% CI 1.41–2.32) and were more likely to require emergency admission (adjusted RR 1.93, 95% CI 1.35–2.77). Interpretation: Despite the widespread distribution of guidelines for asthma pharmacotherapy, inappropriate use of asthma medications persists (specifically excessive use of inhaled short-acting β-agonists combined with underuse of inhaled corticosteroids). Not only are patients who use medication inappropriately at higher risk for fatal or near-fatal asthma attacks, but, as shown in this study, they use significantly more health care resources than patients with appropriate medication use.

Cost and effect

Abstract: Pricing life: Why it's time for health care rationing Peter A. Ubel Cambridge (MA): MIT Press; 2001 208 pp US$14.95 (paper) ISBN 0-262-71009-9 Peter Ubel, a general internist who has published extensively on ethics, equity and medical decision-making, has written a book on health care rationing

Bioethics for clinicians: 21. Islamic bioethics

Abstract: ISLAMIC BIOETHICS DERIVES FROM A COMBINATION OF PRINCIPLES, duties and rights, and, to a certain extent, a call to virtue. In Islam, bioethical decision-making is carried out within a framework of values derived from revelation and tradition. It is intimately linked to the broad ethical teachings of the Qur’an and the tradition of the Prophet Muhammad, and thus to the interpretation of Islamic law. In this way, Islam has the flexibility to respond to new biomedical technologies. Islamic bioethics emphasizes prevention and teaches that the patient must be treated with respect and compassion and that the physical, mental and spiritual dimensions of the illness experience be taken into account. Because Islam shares many foundational values with Judaism and Christianity, the informed Canadian physician will find Islamic bioethics quite familiar. Canadian Muslims come from varied backgrounds and have varying degrees of religious observance. Physicians need to recognize this diversity and avoid a stereotypical approach to Muslim patients.

Addiction and the brain: the role of neurotransmitters in the cause and treatment of drug dependence

Abstract: RECENT SCIENTIFIC ADVANCES HAVE LED to a greater understanding of the neurobiological processes that underlie drug abuse and addiction. These suggest that multiple neurotransmitter systems may play a key role in the development and expression of drug dependence. These advances in our knowledge promise not only to help us identify the underlying cause of drug abuse and dependence, but also to aid the development of effective treatment strategies.

Effect of domperidone on milk production in mothers of premature newborns: a randomized, double-blind, placebo-controlled trial

Abstract: Background: Varying degrees of success have been reported with strategies to increase milk production when lactation is failing. The objective of this study was to investigate the efficacy of domperidone in augmenting milk production in mothers of premature newborns. Methods: Twenty patients were randomly assigned to receive either domperidone or placebo for 7 days. Milk volume was measured daily. Domperidone levels were measured in randomly selected milk and serum samples on day 5 of the study. Serum prolactin levels were measured before the start of the study, on day 5 and on day 10 (3 days after the last dose of the study medication). Results: Data from 16 patients were available for analysis (7 in the domperidone group and 9 in the placebo group). When compared with baseline values, the mean increase in the volume of milk production from day 2 to 7 was 49.5 (standard deviation [SD] 29.4) mL in the domperidone group and 8.0 (SD 39.5) mL in the placebo group (p Interpretation: In the short term domperidone increases milk production in women with low milk supply and is detected at low levels in breast milk.

Baseline staging tests in primary breast cancer: a practice guideline

Abstract: Background: Breast cancer develops in over 7000 women each year in Ontario. These patients will all undergo some staging work-up at diagnosis. The Breast Cancer Disease Site Group of the Cancer Care Ontario Practice Guidelines Initiative reviewed the evidence and indications for routine bone scanning, liver ultrasonography and chest radiography in asymptomatic women who have undergone surgery for breast cancer. Methods: A systematic review of the published literature was combined with a consensus interpretation of the evidence in the context of conventional practice. Results: There were 11 studies of bone scanning reported between 1972 and 1980, involving a total of 1307 women; bone scans detected skeletal metastases in 6.8% of those with stage I breast cancer, 8.8% with stage II and 24.5% with stage III. A total of 5407 women participated in 9 studies of bone scanning reported between 1985 and 1995; in these studies, bone scans detected skeletal metastases in only 0.5% of women with stage I disease, 2.4% with stage II and 8.3% with stage III. Among 1625 women in 4 studies of liver ultrasonography reported between 1988 and 1993, hepatic metastases were detected in 0% of patients with stage I disease, 0.4% with stage II and 2.0% with stage III. Among 3884 patients in 2 studies of chest radiography published in 1988 and 1991, lung metastases were detected in 0.1% of those with stage I, 0.2% with stage II and 1.7% with stage III. False-positive rates ranged from 10% to 22% for bone scanning, 33% to 66% for liver ultrasonography and 0% to 23% for chest radiography. The false-negative rate for bone scanning was about 10%. Recommendations: The following recommendations apply to women with newly diagnosed breast cancer who have undergone surgical resection and who have no symptoms, physical signs or biochemical evidence of metastases. • Routine bone scanning, liver ultrasonography and chest radiography are not indicated before surgery. • In women with intraductal and pathological stage I tumours, routine bone scanning, liver ultrasonography and chest radiography are not indicated as part of baseline staging. • In women who have pathological stage II tumours, a postoperative bone scan is recommended as part of baseline staging. Routine liver ultrasonography and chest radiography are not indicated in this group but could be considered for patients with 4 or more positive lymph nodes. • In women with pathological stage III tumours, bone scanning, liver ultrasonography and chest radiography are recommended postoperatively as part of baseline staging. • In women for whom treatment options are restricted to tamoxifen or hormone therapy, or for whom no further treatment is indicated because of age or other factors, routine bone scanning, liver ultrasonography and chest radiography are not indicated as part of baseline staging.

PubMed: bridging the information gap

Abstract: On-line literature searches of bibliographic databases such as PubMed ([www.ncbi.nlm.nih.gov/entrez/query.fcgi][1]) are now integral to the lives of clinicians. A huge amount of knowledge can be gleaned from even a basic PubMed search, while the use of advanced functions can add speed and focus. The