CMAJ 1997;157:625
© 1997 Canadian Medical Association
Although research should lead us to the truth, nothing stays true forever. Researchers test theories, and when the results don't fit, the theory changes. Our understanding of the relation between atrial fibrillation and stroke is an example. People with normal mitral valves and atrial fibrillation -- nonvalvular atrial fibrillation (NVAF) -- have a risk of stroke 5 times greater than do those in sinus rhythm. The accepted explanation has been that stasis of blood in the fibrillating left atrium results in clot formation. But is stasis really the cause? Susan Kahn and colleagues at McGill University report the results of detailed blood studies of 74 patients with NVAF and show that these patients had humoral hypercoagulability (page 673 and page 685). Their research adds to the existing evidence of a strong association between elevated concentrations of hemostatic factors, on the one hand, and NVAF and stroke, on the other. Seth Landefeld of the University of California, San Francisco discusses the importance of these findings (page 695). Research in this area may allow us to identify patients at greater risk of stroke and may ultimately allow us to develop more specific drugs for stroke prevention. In the meantime, warfarin therapy remains the best option and should be considered for any patient with NVAF.
One truth that clinical research has not discredited is that all drugs have side effects; a corollary truth is that rarer side effects take longer periods of drug use to become evident. The editors of the New England Journal of Medicine lifted their usual news embargo to permit the public release of stunning findings from the Mayo Clinic. Valvular heart disease was reported in a case series of 24 young women taking the commonly used appetite suppressants fenfluramine and phentermine ("fen-phen") in combination. Derek Boughner of the University of Western Ontario notes that the histopathologic features of the valvular lesions were identical to those seen in carcinoid syndrome (page 705). It is known that fenfluramine inhibits serotonin reuptake in the brain and that phentermine interferes with its pulmonary clearance. Physicians should carefully evaluate women who are taking these drugs and experiencing cardiovascular symptoms.
As Norman Mailer said, there is nothing safe about sex and never will be. Howard Ovens and Joanne Permaul-Woods of the University of Toronto surveyed 600 emergency physicians in Ontario on sexual involvement with patients (page 663). About 9% reported being aware of a colleague in emergency practice who had had sex with a patient, and 6% reported sexual involvement with a patient themselves. Is this acceptable? About two-thirds of respondants felt that such behaviour was always an abuse of power and supported zero tolerance. The remainder felt that it could be acceptable in a nonprofessional setting for physicians to ask former patients for a date.
Death has been much in the news. Correspondant Nancy Robb gives in-depth coverage of the debacle involving Dr. Nancy Morrison and the Queen Elizabeth II Health Sciences Centre in Halifax (page 757). Why was Morrison charged with first-degree murder? How did the hospital get it wrong? An external review has indicated that if the hospital had reported the death openly and promptly, Morrison would not be facing such a devastating charge.--JH
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