Highlights of this issue

CMAJ 2000;163(4):385

Over the 5 years before 1997 British Columbia hospitals experienced declines in the number of short-stay beds of 30.0% and in the average hospital stays of 12.9%. For elderly people this has led to 27.3% and 14.4% fewer days in acute and extended care beds respectively. Samuel Sheps and colleagues have analysed the shifts in health care use by elderly people between 1986–1988 and 1993–1995, stratifying the population by age and category of use, and using mortality as an indicator of adverse outcome. The proportion who required neither inpatient services nor home care increased (from 45.4% to 47.5%), whereas it decreased among those who remained in facility care the entire time (from 6.6% to 6.2%). Similar small changes were observed in other use categories. There was no change in mortality overall. In an accompanying commentary Noralou Roos describes the consistency of these results with others and contrasts them with media reports of crisis and suffering.

Necrotizing fasciitis is a rapidly progressive necrotic soft-tissue infection associated with high mortality (24%–58%). Early recognition and treatment, key to survival, are complicated by the need to differentiate the disease from more common, less serious soft-tissue infections. Tauyee Hsieh and coworkers compare the features of 8 pediatric cases of necrotizing fasciitis (confirmed at surgery or by pathological examination) with those of control subjects admitted and treated for cellulitis. The children with necrotizing fasciitis were more likely than those with cellulitis to present with a generalized erythematous rash, a "toxic appearance," a history of fever and a lower platelet count.

Although the efficacy of antihypertensive therapy is well established, there is incomplete consensus regarding treatment thresholds for patients with uncomplicated, mild essential hypertension. In these circumstances individual doctor and patient preferences are liable to be influential. Finlay McAlister and his colleagues have measured the minimal clinically important difference as perceived by patients and physicians. In general, physicians accepted a smaller difference than did patients; however, there was wide variability in response, including a subset of patients apparently willing to accept therapy without demonstrable benefit.

In 1996 a new variant of spongiform encephalopathy, variant Creutzfeldt–Jakob disease, was identified in the United Kingdom. The causative agent is thought to be the bovine spongiform encephalopathy prion, ingested with contaminated food. The risk of transmission through blood transfusion is unknown, but the exclusion of potentially infected donors has been recommended. In a model adopted by Héma-Québec, the risk of infection was assumed to be proportional to the duration of potential exposure — in this case time spent in the UK — and the threshold of exposure was determined by the maximum loss of donors (3%–5%) that the blood supply would tolerate.

Richard Long reviews the mechanisms and theory behind current strategies for tuberculosis control and describes how substandard treatment results in the selection of drug-resistant strains. Acquired resistance arises in developing countries owing to scarce resources and difficult access to health care, and in developed countries owing to difficulties in monitoring compliance with drug therapy. Individual risk factors include living in high-prevalence areas, exposure to resistant strains and previous antituberculous drug therapy. Treatment depends on state-of-the-art drug susceptibility testing and an uninterrupted supply of a wide range of drugs. In TB control programs, prevention should be given priority, with appropriate prescription of 2 or more agents and careful monitoring of compliance.

© 2000 Canadian Medical Association or its licensors