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 Canadian
Medical Association Journal
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Highlights of this issue
Malaria in travellers
Psychosocial factors as selection criteria
Guidelines for cardiac tests or treatment increasingly incorporate psychosocial factors into patient selection criteria. This potentially introduces social value judgements into clinical decisions and decisions about the rationing of care. In the textbooks and guidelines reviewed by Mita Giacomini and colleagues, psychosocial characteristics are portrayed as either risk factors intrinsic to the candidate or as indicators of need for special intervention. However, they tend to be inadequately described and substantiated and, if misapplied, could limit access to health care for vulnerable and marginal social groups. In a related commentary, John Dossetor provides an ethicist's view. If, as seems increasingly likely, clinical practice guidelines are to be used in selecting patients for special services that are limited or rationed, they will require careful ethical analysis. Inappropriate use of asthma medication
Current guidelines define appropriate asthma management as optimization of inhaled corticosteroid doses and use of short-acting ß-agonists fewer than 4 times weekly. Aslam Anis and coworkers examined the correlation between the use of ß-agonists, inhaled corticosteroid therapy and medical services among 23 986 patients. Of the 3069 (12.8%) who had prescriptions filled for 9 or more canisters of ß-agonists in 1995, 763 (24.9%) used no more than 100 µg/d of inhaled beclomethasone. Patients with inappropriate use of ß-agonists visited more physicians for their prescriptions (1.8 v. 1.4), were more likely to be admitted to hospital (adjusted relative risk [RR] 1.68, 95% confidence interval [CI] 1.25–2.26) and were more likely to require emergency admission (adjusted RR 1.93, 95% CI 1.35–2.77) than patients with appropriate medication use. In a related commentary Nicholas Anthonisen considers why patients who need inhaled corticosteroid therapy might not be using it: cost, lack of immediate symptomatic relief and failure of health care professionals to communicate its value. Eliciting patient histories Donald Redelmeier and colleagues continue their series on "Problems for Clinical Judgement" with a study of the cognitive traps that underlie the task of obtaining an insightful history of present illness. Patients may make errors in comprehension, recall, evaluation and expression. The authors describe examples of each and provide suggestions for how to avoid them. Angiogenesis in cancer
Copyright 2001 Canadian Medical Association or its licensors |
Although the incidence of drug-resistant malaria is increasing worldwide, it remains both preventable and treatable, given appropriate care. Kevin Kain and colleagues report 7 cases in which Canadian travellers or visitors to Canada died of malaria. Features of these cases included nonexistent or inappropriate malaria prophylaxis, delays in seeking medical attention and inadequate care while abroad, and delays in diagnosis upon return to Canada. Physicians and travellers must educate themselves about malaria risk, prevention, diagnosis and management, ideally with support from the travel industry and airlines. Further research is required, since international travel and globalization can only increase the importation of globally important diseases to Canada.
Most deaths from cancer are due to metastatic disease. The biological heterogeneity of tumour cells precludes the discovery of an easy monotherapy, but tumorigenesis and metastasis rely on certain critical processes, including the elaboration of vasculature to supply the tumour. Jonathan Izawa and Colin Dinney review what is known about angiogenesis in prostate and other urological cancers. Because proangiogenic factors are believed to enhance tumorigenicity and metastasis, their measurement may be used to provide prognostic information. Furthermore, agents that disrupt angiogenesis have been shown to inhibit tumour growth in vitro and in animal models, and phase I studies of antiangiogenic therapy in combination with chemotherapy are underway.