Highlights of this issue

CMAJ 2000;163(9):1125

War rivals infectious disease as a global cause of morbidity and mortality, not only during active fighting, but also as a consequence of the destruction of infrastructures and the environment, the displacement of populations and the ongoing presence of radioactivity, weapons and toxins. Four wartime activities have a prolonged and pervasive impact on the environment: nuclear weapons production and testing, aerial and naval bombardment, dispersal and persistance of land mines and military ordnance, and the use and storage of military despoilants, toxins and waste. Jennifer Leaning surveys the scale and impact of military activities on the environment and human health and concludes that much still needs to be understood about the destructive potential of war on ecosystems.

Another tragic consequence of war is sexual violence against women and children. It occurs because of the breakdown of social structures, but it can also be used systematically to subdue and demoralize a population and to force pregnancy as a means of "ethnic cleansing." According to Leslie Shanks and Michael Schull, the immediate actions of medical personnel working in conflict settings should include recognition and documentation of the sexual violence, and provision of antibiotic prophylaxis and emergency contraception. Public advocacy can sometimes be effective in bringing pressure to bear on responsible governments, and recently cases of rape have been successfully prosecuted as a war crime and as an act of genocide.

In a related commentary Pauline Alakija writes about her work as a forensic pathologist investigating war crimes in Kosovo for the United Nations.

Sildenafil (Viagra) has revolutionized the treatment of erectile dysfunction. Because erectile dysfunction and cardiovascular disease often coexist, concerns have arisen about the effect of sildenafil on cardiovascular disease, or its interaction with cardiovascular drugs. Evangelos Michelakis and colleagues review the mechanism of action, indications and interaction. Sildenafil does not appear to increase the incidence of myocardial infarction or death. Its use is absolutely contraindicated in patients requiring nitrates, and relatively contraindicated in patients with active coronary ischemia, heart failure associated with borderline hypotension or low blood volume, a complicated multidrug hypertensive regimen or concomitant use of drugs that inhibit the P₄₅₀ pathway.

Induction of labour is appropriate when the potential risks of continuing a pregnancy outweigh the benefits. Induction is associated with increased risk for fetal distress, uterine hyperstimulation and cesarean section. In an attempt to reduce what was felt to be a high induction rate, the British Columbia's Women's Hospital and Health Centre instituted a continuous quality improvement program, involving the development of clear criteria for induction, a new induction booking system and daily peer review of inductions, with particular attention given to communicating changes and their rationale to caregivers. Susan Harris and colleagues describe the implementation and outcome of the program.

On the basis of results showing the success of screening mammography in reducing breast cancer mortality, 22 countries, including Canada, had established population-based screening programs by 1998. Dana Paquette and coworkers report on the 1996 screening results for 7 provincially organized screening programs. The recall rates after first and subsequent screens were 9.5% and 4.6% respectively and the cancer detection rate per 1000 women was 6.9 and 3.8 respectively. In a related commentary Anthony Miller considers the additional factors required for effective screening programs: validity and acceptability of the screening test, early diagnosis of progressive disease, minimal diagnosis of nonprogressive disease, effective therapy and good compliance of the at-risk population.

Copyright 2000 Canadian Medical Association or its licensors