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 Canadian
Medical Association Journal
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Highlights of this issue
Addiction and the brain
Changing primary care practices
Implementation of evidence-based guidelines is not a passive process. The evidence suggests that multifaceted interventions are more effective than single ones in changing physician behaviour. Jacques Lemelin and colleagues describe a randomized controlled trial of an 18-month multifaceted intervention delivered by nurse facilitators to improve implementation of 8 recommended preventive manoeuvres by health service organizations. An absolute improvement of 11.5% in the preventive performance index was found in the intervention group (p < 0.001), and of 7.2% in the proportion of eligible patients receiving the recommended manoeuvres (p = 0.008). In a related commentary Marie-Dominique Beaulieu considers how the concept of the facilitator may be further refined. Men, women and HIV
Injection drug use accounts for a rising proportion of AIDS cases among women. In a cohort of injection drug users in Montreal, Julie Bruneau and colleagues determine sex-related differences in risk behaviours that could have implications for the development of preventive and clinical interventions. Needle-sharing with a person known to be HIV positive (odds ratio [OR] for men 2.44, 95% confidence interval [CI] 1.72–3.46; OR for women 3.03, 95% CI 1.29–7.13) and needle-sharing in the past 6 months (OR for men 0.61, 95% CI 0.44–0.85; OR for women 0.32, 95% CI 0.14–0.73) were independently associated with HIV infection. Among men, other variables associated with HIV infection were homosexual or bisexual orientation, preference for cocaine over heroin, frequency of injection drug use, and obtaining needles at a pharmacy or through needle exchange programs. Among women, other variables were obtaining needles at shooting galleries and not participating in a treatment program. In a related commentary Patricia Spittal and Martin Schechter tell one woman's story to illustrate common themes of power imbalance, physical abuse, commercial sex work, drug use, vulnerability and despair. Brain death In this latest article of the Bioethics for Clinicians series, Neil Lazar and colleagues explore the ethical, cultural, religious and legal issues surrounding brain death. Medicine's adoption of brain death as signalling the death of the person may come into conflict with cultural and religious traditions that hold that death has not occurred until all bodily functions cease, or with traditional legal definitions of life based on heartbeat and respiration, even if artificially maintained. The authors outline an approach to establishing a diagnosis of brain death in clinical practice, as well as the legal and ethical requirements that must be satisfied, particularly when organ donation is considered. Osteoporosis detection and treatment
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Addictive substances modulate the activity of the circuit in the brain that rewards behaviours important for survival, such as eating and sexual activity. An important component of that circuit is the dopaminergic pathway of the medial forebrain bundle (also called the mesolimbic dopamine pathway). Denise Tomkins and Edward Sellers review the mechanism of action of nicotine, alcohol, stimulants (cocaine and amphetamines) and opiates, all of which directly or indirectly increase the release of dopamine within this pathway. The authors discuss approaches to the treatment of addiction that attempt to apply this understanding.
The value of bone densitometry screening depends on how the results influence management. Nicole Fitt and colleagues report on a prospective study involving 383 women over 50 years of age undergoing bone densitometry for the first time. Of the 335 women who completed the 3-month follow-up, 137 (40.9%) were found to have osteopenia and 79 (23.6%) osteoporosis. Of those with osteoporosis, the proportion receiving either hormone replacement therapy or bisphosphonate therapy increased from 15.2% before the scan to 63.3% after the scan. Factors independently associated with the initiation of either therapy included bone densitometry result showing osteoporosis (OR 7.2, 95% CI 1.7–30.3), subjects' perception that their scan showed bone loss (OR 13.5, 95% CI 4.0–45.5) or that they were unclear about the results (OR 5.4, 95% CI 1.6–18.8), and discussion of the results with a physician (OR 5.5, 95% CI 1.9–16.0).