News and analysis · Nouvelles et analyses

CMAJ 1999;161:1381-5

• New billing system for Mountie patients
• Advise patients against hoarding drugs because of Y2K fears, MDs asked
• NS sets precedent with maternity benefits for physicians
• Built-in antibiotics to help prosthesis patients
• Canada's pitiful ranking in imaging technology spurs project
• Pulse: Logging on in record numbers
• Ontario police warn of jimson weed dangers
• This month in medical history: the tragic life of Typhoid Mary
• Research Update:
  • Light at the end of the catheter for heart-transplant patients
  • Scientists working on killer cure

Physicians who treat Canada's Mounties must use a new billing procedure as of Dec. 13, the RCMP advises. The program, which covers uniformed officers but not their family members, will now be administered by Blue Cross and use the same system employed by Veterans Affairs Canada; benefits will remain the same. To register as a provider or to obtain a provider kit, call Blue Cross, 888 261-4033.

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Canada's physicians are being asked to discourage patients from hoarding or stockpiling drugs because of fears related to potential Y2K problems. "Any hoarding or stockpiling could cause a greater threat to the availability of medicines than computer failure," the Pharmacy Supply Chain Task Force says. It was created earlier this year to deal with hoarding and other issues related to the Y2K bug.

"Patients should know that if everyone gets an extra supply of drugs, then it might start a shortage," says Noelle-Dominique Willems of the Canadian Pharmacists Association. She suggests that if patients are worried, they should seek reassurance from their pharmacists or physicians.

Willems says pharmacists usually have a "blip" of extra prescriptions to fill about Dec. 15 as people stock up to avoid having to make a holiday visit to a pharmacy, and drugstores want to avoid a bigger-than-normal rush this year. She says shortages occur regularly within the drug-supply chain, but they are usually solved quickly.

Willems says the only problems identified by the end of October involved some hospitals that appeared to have begun stockpiling drugs. She says they are being warned by drug companies that normal return policies will not be followed if hospitals try to return the drugs in the new year.

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The Medical Society of Nova Scotia has set a precedent for medical associations in Canada and perhaps the US by providing maternity benefits for female members who have babies or adopt children. The program begins next year.

Having a child can be expensive: Dr. Anita Palepu with her 11-week-old daughter, Saffrin Photo by: Steve Wharry

Society President Michael Riding says this type of coverage is long overdue and hopes other CMA divisions will follow suit. "The number of women coming out of medical school is growing and we know that governments across the country have concerns about keeping these young women in practice," says Riding. "They need to be encouraged to provide both primary and obstetrical care. I think we, as a society, have a duty and responsibility to help make this happen. Nobody can share childbearing with these women and I think special steps have to be taken to ensure that they don't have to postpone childbearing because they can't afford it."

He points out that doctors who give birth or adopt children face a significant loss of income. In many cases, this can amount to as much as $50 000 in lost income, as well as costs associated with locum coverage and overhead. Although details are not final, benefits will likely begin at the time of childbirth and will amount to $15 000 over a 17-week period. There will be no cost to participants; the society's benefit program makes it possible to set aside $500 000 a year to cover expences.

"It will mean mothers won't be forced to go back to work any more quickly than they would in almost any other kind of job," Riding says. — Dorothy Grant, Hammonds Plains, NS

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Patients who develop infections following hip and knee replacement surgery may benefit from a new type of prosthesis that releases built-in antibiotics until a new joint can be implanted.

Prostalac (prosthesis of antibiotic-loaded acrylic cement) hip and knee joints were developed over the past decade by Dr. Clive Duncan, head of the Department of Orthopedics at Vancouver Hospital, Dr. Bas Masri, Dr. Chris Beauchamp and Nancy Paris-Seeley, a biomedical engineer at the British Columbia Institute of Technology, and their colleagues. They have been tested on hundreds of patients at the Vancouver Hospital and the Mayo Clinic Scottsdale in Arizona, where Beauchamp now works. Health Canada approval has already been obtained, and approval from the US Food and Drug Administration is being sought.

Hip joint being inserted in surgery (Photo by: Dr. Clive Duncan)

About 1% of North American joint-replacement patients experience infections. Previously, patients needed bed rest and a course of antibiotics for several weeks. The only other option for in situ antibiotics has been "beads" of antibiotic-loaded cement, but the surgical and engineering team wanted to give patients a functioning joint along with the medication.

The main engineering challenge was to create a temporary joint, explained Paris-Seeley. The researchers wanted a simple press fit, similar to home-made Popsicle moulds, that could be inserted and popped out later. The eventual solution was to create a set of small, medium and large moulds. The joints are made in the operating room, where the surgeon chooses the antibiotic, powders it and combines it with bone cement, then sets it in the appropriate mould. Stainless steel is used for the stem parts of the joints and the cement coating interfaces with the bone surfaces. "We wanted to go with inexpensive materials that would do the job," says Paris-Seeley.

The procedure takes about 20 minutes longer than conventional joint surgery. Surgeons are "very enthusiastic" about the devices, says Duncan. He says the antibiotics are "extraordinarily effective" because a huge dose stays in the infected area while the rest is absorbed very slowly into the bloodstream.

Duncan says the joints reduce the length of hospital stay from 18 days if the patient is resting in bed without an artificial joint to 6 days. Rehabilitation time is also considerably shorter. — Heather Kent, Vancouver

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Industry representatives, researchers and health professionals are uniting to map Canada's future needs for medical-imaging technology. Industry Canada, which brought these divergent players together for its Medical Imaging Technology Roadmap project, hopes to identify technologies that will meet market demand and improve patient care over the next 4 to 10 years. "Improving medical care has been married with making industry more competitive," says project facilitator Diane Law. The completed roadmap is due in March 2000.

Dr. Brian Lentle, one of 68 roadmap committee members and past president of the Canadian Association of Radiologists, says the effort comes at a crucial time. "We've suffered from our failure to invest in technology," says Lentle. "We have a substantial technical deficit now that is a problem."

Canada recently slipped to the bottom one-third of countries in the Organization for Economic Cooperation and Development in terms of technology availability. With CT scanners, for example, Canada ranked 21st among 28 countries; for lithotriptors the country ranked 19th among 22 countries, and for MRI machines 19th among 27 countries. "I wonder if health care is this expensive because we don't fully benefit from high technology like radiology," says Lentle.

Part of the problem is that Canada doesn't have a large indigenous manufacturing capacity. "I'd love to see some of those big cheques go to Canadian companies," he says.

Part of the roadmap's aim is to alert industry to technology's potential and to acquaint users with what's available in Canada. "We're bringing people together who wouldn't normally get together," says Law. "In the end, the process is probably as important as the document. The value is in people bringing information together."

The roadmap's discussion paper, completed last March, set the stage for the formation of 5 working groups to assess future needs and other issues. Lentle is cautiously optimistic about the end result, but notes that "they're expecting a great deal without putting much [money] into it."

The project is one of a series of roadmaps that Industry Canada is facilitating; others include forestry and aerospace. For more information, visit http://strategis.ic.gc.ca/medimage — Barbara Sibbald, CMAJ

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   | Other Pulse articles / Autres chroniques Médicogramme |

Results from the CMA's 1999 Physician Resource Questionnaire (PRQ) point to a notable increase in the number of physicians who use the Internet, with the proportion rising from 56% in 1998 to 66% in 1999. Of those who do not yet log on, 42% indicated that they plan to do so in the coming year. Although male physicians are more likely to use the Internet than females (70% versus 58%), the gap is narrowing. In 1998, 61% of male physicians used the Internet, compared with 44% of female physicians.

Almost two-thirds (63%) of Canadian doctors now use email, up markedly from 51% in 1998 and 37% in 1997. The proportion of physicians who use the Internet to perform searches of bibliographic databases is also up substantially from 1998 (53% versus 42%), as is the proportion ordering documents and books online (27% versus 13%).The CMA Online Web site was visited by far more PRQ respondents in 1999 (27%) than in 1998 (15%), a fact that may help explain why CMA Online now ranks among the world's top 20 000 Web sites. (According to Netscape, its current ranking, in terms of popularity, is 19 592. In comparison, the site operated by the College of Family Physicians of Canada ranks 223 470, while the Medical Post site stands at 457 951. The World Wide Web is currently home to more than 7 million Web sites. — Ed.)

The proportion of physicians who accessed the CMA's online Clinical Practice Guideline Infobase jumped from 9% in 1998 to 21% in 1999. In 1999, 50% of all Canadian physicians visited Web sites intended for physicians, and 41% visited CME Web sites (see Figure).

This column was written by Shelley Martin, Physician Survey Analyst with the CMA's Research Directorate. Readers may send potential research topics to Patrick Sullivan (sullip@cma.ca; 613 731-8610 or 800 663-7336 x2126; fax 613 565-2382.)

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Police in London, Ont., recently asked gardeners to destroy seed pods on any jimson weeds on their properties. The request came after at least 5 local teenagers ingested the seeds in pursuit of a cheap, legal high. For all of the teens, the trips ended in hospital. One 14-year-old spent a night in intensive care, drifting in and out of consciousness and hallucinating; 6 staff members were needed to restrain him.

The nearby communities of Brampton, Midland, Waterloo and Hamilton have experienced similar problems in the past 2 years, and similar poisonings have also been reported in Quebec. A year ago, the US National Clearinghouse for Alcohol and Drug Information reported that jimson weed poisonings were on the increase among teens.

Detective-Constable Steve Cochrane of the London Police said the plant is not covered under Canada's Controlled Drugs and Substances Act, but ought to be. "It's very dangerous," he said. "There's a sense of abuse, an element of danger." London Police intend to lay charges if sellers misrepresent the seeds as another drug.

Jimson weed (Datura stramonium) is also known as devil's apple, fireweed, stinkweed and stinkwort. It is both a potent hallucinogen and highly toxic. According to the Atlanta-based Centers for Disease Control and Prevention, symptoms of poisoning may include dry mucous membranes, thirst, difficulty swallowing and speaking, blurred vision and photophobia, followed by hyperthermia, confusion, agitation, combative behaviour, urinary retention, seizures and coma. As one cliché-loving nursing supervisor told the Salt Lake Tribune last year: "They are red as a beet, dry as a bone, blind as a bat and mad as a hatter."

All parts of the plant are poisonous, although the highest concentrations of the anticholinergic agent are found in the seeds (typically equivalent to 0.1 mg of atropine per seed.) A student hospitalized last month in London reported ingesting just 1 seed.

Recreational users may ingest seeds or prepare jimson-based tea or cigarettes. The plant is also used in folk medicine to make topical salves and poultices. Some teens learn how to use the plant through Web sites and newsgroups. However, most newsgroups accessed by CMAJ described it as a bad trip. "The high lasts about 36 to 48 hours," said one. "It will allow you to do very stupid and dangerous things." — David Helwig, London, Ont.

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On Nov. 11, 1938, the most infamous typhoid carrier in medical history died after a quarter century of forced exile. Mary Mallon was born in Ireland in 1869 and worked as a cook for wealthy New Yorkers. In 1906 she was hired by a banker living in a rented house in Oyster Bay, Long Island. When typhoid fever struck 6 of its 11 occupants, the property's owner hired George Soper, a sanitary engineer, to investigate. Salmonella typhosa had been identified in the 1880s. Soper was aware that it spread through contaminated water and suspected the possibility of carriers. He traced Mallon's employment history and discovered that typhoid had struck in 7 of the 8 families she had worked for, with 22 cases between 1900 and 1907.

In March 1907 Soper told Mallon she was spreading typhoid and demanded samples of feces, urine and blood. She refused. Soper enlisted the help of the New York City Health Department but it could not persuade Mallon either. Finally, under police escort, Mallon found herself in the Willard Parker Hospital, where high concentrations of typhoid bacilli were confirmed in a stool specimen.

She was quarantined in an isolation cottage on the grounds of Riverside Hospital in North Brother Island, NY. In 1909 she sued the health department for her release, but it was not granted. However, a year later a new health commissioner released Mallon, based on her promise not to work as a cook.

She didn't keep the promise. Having eluded the authorities, "Typhoid Mary" resurfaced in 1915 when an outbreak of 25 new cases of typhoid occurred at the Sloane Memorial Maternity Hospital, where Mallon was working as a cook under the name "Mrs. Brown." She spent the rest of her life in isolation and died in 1938.

To the end, Mary Mallon rebelled against her incarceration. She maintained that she was healthy and never had typhoid. Her story continues to evoke conflicting emotions and is often cited during debates on the dilemma between the rights of an individual versus the rights of society. — Dr. Venita Jay, Toronto

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Scientists at the Ontario Cancer Institute and Alberta's Cross Cancer Institute have found a way to use a toxin produced by the deadly Escherichia coli bacteria to purge cancer cells from bone marrow before transplantation.

Researchers are using a toxin called SLT-1 to clean blood cells by taking advantage of a receptor on the surface of the cancer cells that is recognized by the toxin. The toxin is removed from the blood cells prior to the reinfusion of stem cells into the patient.

Researchers say that although the toxin kills a broad range of cancer cells, particularly breast, lymphoma and multiple myeloma cells, it does not kill healthy blood stem cells. "There is a lot more work to be done to refine the technique and to ensure safety, but this could prove to be an important advance for myeloma patients and perhaps others," said Dr. Linda Pilarski, professor of oncology at the Cross Cancer Institute at the University of Alberta.

A group of researchers in Toronto led by Dr. Jean Gariépy originally pioneered the new technique while grappling with the failure of high-dose chemotherapy during stem cell transplantation, possibly caused by the reinfusion of contaminated tumour cells in the stem cell graft.

Dr. Andrew Belch, also an oncology professor at the Cross Cancer Institute, said a "clean" graft provided by the use of the toxin may help improve survival. "In studies using identical twin grafts, patient survival appears to be better than that when the patient's own cells are used for the graft, probably because the graft from the healthy twin is disease-free," said Belch. "We hope the toxin-based purging will provide a disease-free graft for the majority of patients who have no twin."

Results of the studies conducted by Belch and Pilarski were published in the Oct. 15 issue of Blood. — Steve Wharry, CMAJ

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