Highlights of this issue

CMAJ 1999;161:1377

• Time to put the Canadian Institutes of Health Research on trial [Editorial]

Surely it is time, writes David Sackett, for Canadians to place the Canadian Institute for Health Research (formerly the Medical Research Council of Canada) on trial for its failure to support randomized controlled trials (RCTs). Sackett cites 6 Canadian RCTs that have resulted in lives being saved. A further 3 RCTs have shown that certain treatments that performed well at the bench were either useless or harmful at the bedside. In its last 2 competitions the MRC has turned down 40% of the RCT applications judged scientifically sound by its own committee. The opportunity cost, he contends, includes the disability and untimely death of Canadians.

• Use of ß-blocker therapy in older patients after acute myocardial infarction in Ontario [Evidence]

ß-Blocker therapy is underprescribed in elderly patients surviving myocardial infarction (MI). Paula Rochon and colleagues analysed population-based hospital discharge data for 15 542 seniors surviving an MI between 1993 and 1995. They found that 7549 (48.6%) of them were not dispensed a ß-blocker. The odds of not receiving one increased with being 85 years of age or more (adjusted odds ratio [OR] 2.8, 95% confidence interval [CI] 2.5­3.2) , with having high comorbidity (adjusted OR 1.5, 95% CI 1.3­1.8) and with residing in a long-term care facility (adjusted OR 2.6, 95% CI 2.0­3.4). Of the 5453 with no identifiable contraindication to ß-blocker therapy, women were significantly less likely than men to receive this agent (p = 0.005).

• Effectiveness of in vitro fertilization with intracytoplasmic sperm injection for severe male infertility [Evidence]
• New reproductive technologies: Why are we limiting choices for infertile couples? [Editorial]

In 1993 the Royal Commission on New Reproductive Technologies recommended that Ontario discontinue coverage of in vitro fertilization (IVF) techniques for indications other than bilateral fallopian tube blockage because its effectiveness had not been rigorously evaluated. To address this, Raimundo Pinheiro and colleagues have compared the outcomes of 3 groups of patients: 122 couples with male factor infertility treated by IVF with intracytoplasmic sperm injection (ICSI) of fresh sperm from ejaculate, 27 couples with obstructive azoospermia treated by IVF with ICSI of epididymal sperm, and 98 couples with bilateral fallopian tube blockage treated with conventional IVF. No differences in implantation rates (11.0, 10.2 and 10.3 respectively, p < 0.95) or clinical pregnancy rates/cycle (27.9, 29.6 and 28.6 respectively, p < 0.98) were observed. In an accompanying editorial Arthur Leader criticizes the lack of progress since 1993 and suggests that most infertile Canadians are being denied reproductive choice.

• Powassan encephalitis [Editorial]
• Powassan encephalitis: a case report with neuropathology and literature review [Education]

A case of meningoencephalitis caused by the Powassan virus is reported by Bassam Gholam and colleagues. The patient contracted the infection from a tick bite while in an Ontario provincial park. Only 27 cases of Powassan encephalitis have been reported in North America. As Edward Ralph comments, because there are no clinical, radiological or laboratory features that distinguish it from other severe forms of encephalitis, including herpes simplex, a thorough epidemiological history is important, both for diagnosis and for the design of preventive measures.

• Recent versus historical trends in preterm birth in Canada [Research Letter]

K.S. Joseph and Michael Kramer comment on recent and historical trends in preterm birth rates in Canada. A 1998 study reported a 9% increase in the rate (from 6.25% in 1981­1983 to 6.81% in 1992­1994), which parallels trends in other industrialized countries. This is likely explained by increased obstetric intervention and multiple births. The authors correct an earlier report that identified a dramatic decline in preterm birth rates in Canada between 1972 and 1986. Graphical examination of the 1972 data indicates that true gestational age (e.g., 37 weeks) was rounded to the nearest lunar month (e.g., 9 months or 36 weeks), and thus a number of term births were misclassified as premature in the earlier data set.

© 1999 Canadian Medical Association or its licensors