Safer injection facilities for drug users in Vancouver
![Figure](https://www.cmaj.ca/content/cmaj/169/8/745/F1.medium.gif)
Figure. Photo by: Anson Liaw
A pilot project launched in Vancouver on Sept. 15 provides injection drug users with a “safer” facility to self-administer illicit drugs under the supervision of a nurse. Against a background of political and social controversy, the facility will attempt to alleviate the complex health problems related to injection drug use, such as bacterial and viral infections, overdose deaths and the public health risk posed by improperly discarded syringes. Although the need for clients to follow certain rules and restrictions is apparent, there is a risk that overly stringent rules will deter users and thus undermine the goal of harm reduction. Among injection drug users surveyed by Kerr and colleagues, 92% said they would be willing to use a safer facility without restrictions, but only 31% stated they would use such a facility under rules proposed by Health Canada. Fry comments on the merits of these requirements.
Risks of viral transmission from blood donors
![Figure](https://www.cmaj.ca/content/cmaj/169/8/745/F2.medium.gif)
Figure. Photo by: Comstock.com
It is well known that a minimal viral load must be present for viral infections to be diagnosed by laboratory testing; hence, a test performed prematurely can give a false-negative result. This is of particular concern in the screening of donated blood: there is a “window period” in which it is possible to miss recently infected donors and thereby contaminate the blood supply. Chiavetta and colleagues analyze a national blood-donor database to determine this risk. Using a mathe- matical model, they estimate risks of 1 in 10 million for HIV, 1 in 3 million for hepatitis C, 1 in 72 000 for hepatitis B, and 1 in 1.1 million for human T-cell lymphotropic virus. They stress that it is the combination of state-of-the-art diagnostic testing and a rigorous donor-selection process that has resulted in our present level of safety.
See page 767
Determining resuscitation preferences of the elderly
Informed consent, mental competence, substitute decision-making and medical futility are some of the difficult variables that enter into discussions between physicians and elderly patients when planning end-of-life care. Physicians themselves may struggle with their own reluctance to address the question of advance directives. In a review, Frank and colleagues find that most patients are comfortable with discussions about cardiopulmonary resuscitation and are willing to be involved in the decision-making process. Unfortunately, they find a paucity of literature that examines how physicians should approach the issue and what they should say to patients. Although it can be surmised that some ways of broaching the subject are better than others, there is at present no evidence to support a specific strategy.
See page 795
Human gene transfer research
![Figure](https://www.cmaj.ca/content/cmaj/169/8/745/F3.medium.gif)
Figure. Photo by: Comstock.com
The emerging technology of human gene transfer dramatically challenges the research and therapeutic paradigm established by classic pharmaceuticals. It is also the subject of much philosophical discourse. In a commentary, Kimmelman argues for a central review body in Canada to monitor research in the field of gene transfer. Although a centralized review agency may duplicate the work of existing mechanisms for clinical and ethical review, the author argues that a certain level of redundancy may be needed to adequately address the safety, ethical and societal issues posed by novel therapies.
See page 781