Highlights of this issue

CMAJ 2001;164(9):1273

In this issue we launch a new series on major advances in the management of acute coronary syndromes. We start with a commentary by series editor Paul Armstrong and an article by David Fitchett and colleagues on the diagnostic triage of patients presenting with chest pain. Patients with similiar clinical presentations have widely varying outcomes. The challenge is to match treatment to risk. Fitchett and colleagues describe the use of background risk, clinical presentation, electrocardiogram results and levels of biochemical markers to assess a patient's risk of myocardial infarction or death. Future topics in the series include the development of low-molecular-weight heparins, new platelet aggregation inhibitors, new pharmacologic approaches to fibrinolytic therapy and advances in catheterization.

Thrombolytic therapy reduces the risk of death after an acute myocardial infarction. Jean-Marc Boucher and colleagues conducted a prospective cohort analysis involving 3741 patients admitted to 44 acute care hospitals to determine age-related rates of thrombolytic use and in-hospital mortality. In-hospital mortality rates rose dramatically with age, from 2.1% among patients less than 55 years of age to 26.3% among those aged 85 years or older. Conversely, the use of thrombolytic therapy decreased with age, from 46.2% to 9.5% in the same age groups. Compared with patients less than 55 years of age, the odds ratios for receiving thrombolytic therapy were 0.68 (95% confidence interval [CI] 0.52–0.89), 0.48 (95% CI 0.35–0.65) and 0.13 (95% CI 0.06–0.26) for patients aged 65–74, 75–84 and 85 years or more, respectively. In a related commentary, David Thiemann and Steven Schulman review the sometimes conflicting evidence on the effectiveness of thrombolytic therapy in elderly patients.

Jacques Allard and colleagues conducted a randomized controlled trial involving 266 community-dwelling elderly people. Of the 127 patients in the experimental group, 80 were subjects of an intervention consisting of a case conference to review their medication and a follow-up letter to their physician with suggested changes in prescribing and evidence-based documentation. For the others in the experimental group, either the subject or the physician declined to participate, or eligibility had changed between initial recruitment and evaluation. Potentially inappropriate prescriptions declined by 0.24 in the experimental group (by 0.31 for those whose prescriptions were reviewed) and by 0.15 in the control group; this difference was not significant in the intent-to-treat analysis. The authors discuss the context and limitations of their study.

Research information in the life sciences has accumulated on a vast scale in the past 10 years. On-line bibliographic databases such as PubMed are integral to the efforts of clinicians to sift through the biomedical literature. However, the scientific abstracts that constitute PubMed represent only one type of biomedical information. Johanna McEntyre and David Lipman describe how the US National Center for Biotechnology Information is integrating PubMed with other information resources, such as full-length research articles, clinical trials databases and molecular biology data, to build a layered approach to biomedical data.

Copyright 2001 Canadian Medical Association or its licensors