Highlights
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## Profile of high-cost users over time

One-third of health care costs are accounted for by 1% of the population. Using routine health care data from Ontario, this study found that about 45% of people in the top 5% cost group in 2009 remained high-cost users in the subsequent year and that one-third remained at that level for all three years studied. Improving the sustainability of the health care system through better management of high-cost users will require different tactics for different high-cost populations, suggest the authors. **See Research, page [182](http://www.cmaj.ca/lookup/volpage/188/182)**

## Resting heart rate and mortality

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/188/3/165/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/188/3/165/F1)

Higher resting heart rate was associated with an increased risk of subsequent all-cause and cardiovascular mortality, finds this meta-analysis of 46 prospective cohort studies representing data on over 1 million patients. A resting heart rate of above 90 beats per minute conferred a significantly increased risk of death. **See Research, page [E53](http://www.cmaj.ca/lookup/volpage/188/E53)**

## Fetal alcohol disorder guideline

![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/188/3/165/F2.medium.gif)

[Figure2](http://www.cmaj.ca/content/188/3/165/F2)

Diagnosis of fetal alcohol spectrum disorder is essential to improve outcomes for affected individuals and families, and to inform pre-pregnancy counselling to prevent future cases. This guideline from the Canada Fetal Alcohol Spectrum Disorder Research Network provides evidence-based recommendations for best practices in the diagnosis of this condition. **See Guidelines, page [191](http://www.cmaj.ca/lookup/volpage/188/191)**

Are all mothers who have children with fetal alcohol spectrum disorder dependent on alcohol and neglectful or unfit parents? Abadir and Ickowicz say no. In this commentary, they argue that clinicians, policy-makers and the public need to collectively assume responsibility for addressing the manifest determinants of health that contribute to the persistence of this disorder. **See Commentary, page [171](http://www.cmaj.ca/lookup/volpage/188/171)**

## HIV treatment as prevention in MSM

RCTs of treatment as prevention have shown significant prevention of onward HIV transmission among serodiscordant couples, but observational studies of clinical practice have not consistently replicated these findings. There are particular concerns among men who have sex with men. O’Byrne and McPherson explore some of the issues. **See Analysis, page [198](http://www.cmaj.ca/lookup/volpage/188/198)**

## Caring for Syrian refugees

A Syrian refugee family is newly arrived in Canada and has an appointment with their new family doctor. Do they require immunizations? What about testing for tuberculosis, hepatitis or HIV? Should they be screened for mental health issues? Using recent prevalence data and guidelines, Pottie and colleagues provide evidence-based recommendations for the care of Syrian refugees in Canada. **See Decisions, page [207](http://www.cmaj.ca/lookup/volpage/188/207)**

## Eye damage from tarantula hairs

![Figure3](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/188/3/165/F3.medium.gif)

[Figure3](http://www.cmaj.ca/content/188/3/165/F3)

A three-year-old boy had eye pain within seconds after holding a Chilean rose tarantula at a birthday party. One year later, encapsulated barbs were still visible in the cornea of both eyes. Yang and colleagues describe why tarantula barbs are so hazardous to the eye and provide an approach to managing exposure to these hairs. **See Cases, page [212](http://www.cmaj.ca/lookup/volpage/188/212)**

## Direct oral anticoagulants

Although direct oral anticoagulants are increasingly prescribed, their use presents challenges for the clinician. These include variable results on clot-based assays such as prothrombin time and a lack of specific antidotes available in practice to reverse their action. Direct antidotes are in phase 3 trials, say Wood and Ackery. **See Five things to know …, page [215](http://www.cmaj.ca/lookup/volpage/188/215)**

## Cystoid macular edema from chemotherapy

![Figure4](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/188/3/165/F4.medium.gif)

[Figure4](http://www.cmaj.ca/content/188/3/165/F4)

Taxane-based chemotherapeutic agents are linked to a serious toxic effect: cystoid macular edema. Clinicians caring for patients undergoing taxane-based chemotherapy should remain alert to visual changes and consider prompt referral to an ophthalmologist, as cessation of treatment can be associated with improvement in vision. **See Clinical images, page [216](http://www.cmaj.ca/lookup/volpage/188/216)**