personal view

limiting consumption of albacore 2 Letters for Personal View are welcomed. tuna. HealthLink BC and Health They should be double-spaced and few er Canada have set different serving than 300 words. The BCMJ reserves the limits and age categories in their fish right to edit letters for clarity and length. consumption recommendations. The Letters may be e-mailed (journal@bcma recommendations also differ some- .bc.ca), faxed (604 638-2917), or sent what from those of the State of through the post. Washington and the US FDA/EPA.3 One of my associates, Dr Laurie Chan, chair of Aboriginal environ- mental health at UNBC, has told me Flu protection for the accompanying document for “In- that cheaper light tuna tends to have fection Control Guidelines in Acute an Hg level 5 times lower than that physicians Care Facilities,” www.phac-aspc.gc found in albacore tuna.4 have recently moved from Ontario .ca/alert-alerte/swine-porcine/ I would sincerely like to know the to BC in rural family practice. I guidance-orientation-ipc-eng.php. background, rationale, and references Iwork in the clinic and hospital The BC Ministry of Health Ser- used by the Ministry of Health and the full-time in Invermere, BC. vices is not planning at this time to CDC to make this recommendation. I In Ontario every doctor’s office follow the Ontario decision to supply remember listening to Ray Copes in a was supplied with a stock of protective physicians’ private offices with pro- meeting one day, and he mentioned masks, gowns, etc., after the deaths of tective equipment as the ministry Continued on page 240 doctors, nurses, and paramedics in the believes it is properly the responsibil- SARS outbreak in Ontario. ity of the physician to ensure that What are the BCMA and the Min- infection control practices are in place istry of Health doing to protect front- in these offices. Liquid Nitrogen line health care workers from the next At the request of Canada’s minis- for Medical Use pandemic outbreak? ters of health, a national advisory Westgen has been providing Liquid Nitrogen Will we be supplied with protec- group reviewed the issue of providing to doctors for the past 10 years. We have tive equipment since we are asked to antivirals as prophylaxis during a pan- established a reputation for prompt, quality deal with these patients in our offices? demic and recommended that govern- service at a reasonable price. Will we be supplied with prophylactic ments not do this. Rather, they empha- We also offer MVE Cryogenic Refrigera- tors in 10 and 20 litre sizes. These can be antivirals for exposed heath care sized that government’s antiviral acquired on a one year LEASE TO OWN workers? stockpiles, with few exceptions, option, a system that allows you to own your —Stephen Arif, MD should be reserved for early treatment tank after a year of low monthly payments Invermere of infection during a pandemic. This which includes free liquid nitrogen for the report and its annexes can also be lease period. The Provincial Health accessed at the Public Health Agency MVE Cryogenic of Canada web site. Refrigerators Officer replies —Perry Kendall, MD • No Stop Charge n response to Dr Arif’s enquiry, I Provincial Health Officer • No Cartage Fees • No Dangerous would refer all BC physicians to Goods Handling Ithe recently posted documents on Charges the Public Health Agency of Canada Why differences in • Lease to own web site, “Interim Guidance—Infec- tuna limits? option Service provided to practitioners on Vancouver tion Prevention and Control Measures ith respect to canned tuna Island, Lower Mainland and Okanagan area. for Health Care Workers in Ambula- in Canada, HealthLink BC For more information contact Westgen at: tory Care Facilities for Human cases W Files recommend that Bri- 1-800-563-5603 Ext. 150 or 778-549-2761 of Swine Influenza A H1N1,” www tish Columbians limit consumption of .phac-aspc.gc.ca/alert-alerte/swine- all types of canned tuna1 whereas porcine/hp-ps-info_amb-eng.php and Health Canada currently recommends

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Continued from page 239 4. Burger J, Gochfeld M. Mercury in canned regarding mercury risk do not apply that he had come across a case of Hg tuna: white versus light and temporal well in the BC context. For British poisoning in a boy that was related to variation. Environmental Research 96 Columbians, information on local pat- some higher-than-normal Hg levels in 2004:239-249. terns of fish consumption, local levels some canned tuna. Is the recommen- of mercury in different fish species, dation based on this incident? I would and local risk factors for elevated blood also like to know which government COHP replies mercury were carefully considered. agency should be looked to for conta- he recommendations in the In addition, the BCCDC and the minant consumption advice. HealthLink BC files have been MOHS categorized the mercury level —Karen Fediuk, RD Tdeveloped based on BC and in different fish species into low (<0.1 Canadian evidence and data indicat- ppm), moderate (between 0.1 ppm and References ing safe and at-risk human body mer- 0.5 ppm), and high (>0.5 ppm) mak- 1. HealthLink BC Health Files. Healthy Eat- cury levels and consumption levels. ing them easier to understand. Health ing: Choose Fish Low in Mercury. The BC Centre for Disease Control Canada has one regulatory cut point www.healthlinkbc.ca/healthfiles/hfile68 (BCCDC) and the Ministry of Health of 0.5 ppm of mercury and has recom- m.stm (accessed 19 February 2009). Services (MOHS) agree with Health mended consumption limits for fresh 2. Health Canada. Mercury in Fish. Con- Canada’s review of mercury toxicity and frozen tuna and canned albacore. sumption Advice: Making Informed levels and the guidelines limiting mer- Health Canada states that canned alba- Choices about Fish. www.hc-sc.gc.ca/ cury to below 1.0 ppm and 0.5 ppm core tuna has higher mercury levels fn-an/securit/chem-chim/environ/ for most fish and shellfish species than other types of canned tuna and mercur/cons-adv-etud-eng.php sold in Canada. But because BC fish therefore does not recommend limits (accessed 19 February 2009). consumption patterns are unique in for consuming other types of tuna. The 3. Washington State Department of Health. Canada and there is regional variation BCCDC and MOHS support group- Fish Facts for Healthy Nutrition. www in mercury levels in the fish available ing all canned tuna, including alba- .doh.wa.gov/ehp/oehas/fish/fishadvisori to consumers across Canada, Health core, into the moderate category. es.htm (accessed 19 February 2009). Canada’s fish consumption guidelines Continued on page 243

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to ensure that the rural clerkship Continued from page 240 ical school with no reference back to remains a sustainable program, we The types of recommendations existing resources (i.e., UBC) makes encourage you to find out more can be confusing, especially between little sense from a time or resource about the initiative and get involved the different canned tuna, and fresh point of view. Our peak need for in any way you can. and frozen. Since the BCCDC and the physicians will hit between 2010 and The rural medicine clerkship is MOHS have focused on local fish and 2030 as the baby boom makes a tran- a valuable program that will help local risk factors, their recommenda- sition from age 65 to 85. After that, to increase the number of physi- tions may be more appropriate. the load on the health care system cians choosing to practise in rural —Shefali Raja, BSc, RD decreases. UBC is currently on track and northern BC. Nevertheless, in Nutrition Committee, to local and distant expansion across order for this important initiative Council on Health Promotion the province. It is accredited and offers to succeed, the students need the programs both through a traditional support of the medical communi- model and an apprenticeship-type ty. With this support, we can work Re: BC needs another model at sites in the Lower Mainland, together to ensure that the future of medical school Vancouver Island, Prince George, presently underserved communi- hile I agree with Dr Mur- Chilli wack, and, coming very soon, ties is improved. ray’s basic assertion that Terrace, Kelowna, Kamloops, and W BC could be graduating Fort St. John. References more MDs (“BC needs another med- You would have to build a massive 1. Stewart MA, Bass MJ. Recruiting ical school,” BCMJ 2009;51[4]:150), infrastructure, both in terms of physi- and retaining physicians in northern I would first suggest a recheck of cal buildings and people, become Canada. Can Fam Physician 1982; the statistics. UBC will graduate accredited, get students through the 28:1313-1318. approximately 256 medical students system, and then have them qualified 2. Rourke J. Strategies to increase the in 2010. With a population of roughly and licensed. The most optimistic enrolment of students of rural origin 4 400 000, that makes for a ratio of 5.8 forecast would have your first MDs in medical school: Recommenda- MDs per 100 000 (not 2.8 MDs). Fur- operational in 10 years. That would tions from the Society of Rural Physi- thermore, Dr Murray speaks in broad give your medical school 10 more cians of Canada. CMAJ 2005;172:62- strokes about Fraser Health having the years of useful lifespan until the pop- 65. courage to move ahead with a second ulation bust removes the demand. It 3. Wilson G, Kelly A, Thommasen HV. “innovative” program. Is he talking seems like a great waste of resources Training physicians for rural and about some odd notion to “fast track” and money when UBC is able to northern British Columbia. BCMJ a medical school de novo at SFU? quickly expand and contract its med- 2005;47:373-376. I would put it to you that patching ical school offering with an infra- together something resembling a med- Continued on page 244

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Continued from page 243 compared to the archaic and old sys- sis, candida hypersensitivity syndrome, structure already built in. tem of block payments per bed. So, also known as over- Don’t waste time and money re- while a new medical school might growth syndrome. It is not to be con- inventing the wheel when you already sound like a solution to our ever- fused with chronic mucocutaneous live next to the world’s best wheel changing needs, perhaps in the inter- . factory. im we could better utilize our facili- The existence of this presumed —Ari Giligson, MD ties to enjoy the full potential of our disorder is based on clinical pictures Delta present graduates. and dubious diagnostic question- —Al Boggie, MD naires. There is no specific diagnostic Competing interests Delta laboratory test. In addition, “no clear Dr Giligson earns a stipend as undergradu- definition of the disease has ever been 1 ate program director for the Department of Re: Let’s support advanced.” Ophthalmology at UBC. The proponents postulated that the “sensitivity” to candida present in the he popular cry these days from y esteemed colleague Dr gastrointestinal tract was responsible politicians and some bureau- Marshall Dahl has conclud- for various systemic symptoms. They Tcrats is that there is a need for M ed that the “almost com- managed this presumed disorder by more doctors. As a retired MD who plete disappearance of formerly seri- dietary manipulation and use of anti- practised and taught in BC from 1954 ous and prevalent problems such as fungal medications. It received much until retirement in 1988, I am con- chronic hypoglycaemia, chronic can- attention in the media and health mag- cerned about the under-utilization of didiasis, chronic Epstein-Barr infec- azines in the past. our existing hospitals. They generally tion, sero-negative Lyme disease, and A position paper of the American operate from 8 a.m. to 4 p.m., Monday toxicity related to dental amalgam” Academy of Allergy and Im - through Friday, handling emergencies must have been due to “the efforts of munology in 1986 stated that the con- whenever they occur. Even with our the naturopaths and other alternative cept was “speculative and unproven.”2 newer and more efficient technologies practitioners” (“Let’s support natur- There is no scientifically valid the waiting lists continue. opathy,” BCMJ 2009;51[4]:150). evidence that cell-mediated sensitivi- In most industries, when needs in - I am sorry to have to disabuse him ty to candida antigens, present in crease, plants operate longer, produc- of that notion—they have all moved about 50% to 70% of normal adults, is ing more results at reduced per-unit to Victoria! Since arriving here in responsible for this condition. costs—as well as providing more “God’s waiting room” they have A randomized, double-blind, employment in a particular field. increased their demands by asking to placebo-controlled study in 42 pre- Surely this approach could apply be tested for, among other things, menopausal women with the pre- to our hospitals. Why not operate from Wilson’s low temperature syndrome sumed diagnosis of chronic candidia- 8 a.m. to midnight, two shifts per day, and adrenal exhaustion, and asking to sis was reported.3 It compared oral and Monday through Saturday? More be treated with ThyroSense, Adrena - vaginal nystatin with placebo. It was patients could be treated and more lab- Sense, and bioidentical hormone found that nystatin did not “reduce oratory and investigative procedures replacement in addition to the black systemic or psychological symptoms (e.g., CAT scans) could be carried out. cohosh, ginseng, and dong quai they more than placebo did.” This would benefit patients and their are already taking. In 1990 the New Jersey attorney attending physicians. Vancouver’s loss is our gain! general secured consent agreements All too often we hear stories of —Gerald Tevaarwerk, MD barring two physicians from diagnos- newly trained MDs having to leave Victoria ing and treating Candida albicans BC (and Canada) to practise their spe- overgrowth syndrome. Both were cialties because of time restrictions in would like to thank Dr Dahl for assessed $3000 for investigative costs our current hospital management. This pointing out a number of formerly and had their medical licence on pro- has become more apparent recently Iserious and prevalent problems bation for 1 year.4 with ill-timed and inappropriate hos- that have almost completely disap- It is not surprising that this pre- pital closures throughout BC. peared from his practice (“Let’s sup- sumed disorder and others are pre- The change I propose would re - port naturopathy,” BCMJ 2009;51[4]: sently with “reduced incidence and quire creation of a new payment for- 150). prevalence.” It is interesting that the mula for hospitals that rewards them In this discussion I elect to com- naturopaths and other alternative for work done (the more the better) as ment on one entity, chronic candidia- practitioners had been spending so

244 BC MEDICAL JOURNAL VOL. 51 NO. 6, JULY/AUGUST 2009 www.bcmj.org personal view much diagnosing and treating recycle plastic bags in Salmon Arm choose to protect our own behinds by this presumed entity and others in the and your bag is just one more useless submitting requisitions, fully expect- past, which are currently being barred item to go in our landfill. ing rejections, the patients would get in some jurisdictions. Please forgo the plastic wrap and confused and worried that they are I am not aware of any report of simply label the magazine—like in the missing out on a test that is recom- evidence-based studies published in good old days before plastic and land- mended by the powers that be! peer-reviewed, reputable journals fills became inseparable. —Peter Yeung, MD supporting the validity of the various —W. Peter Barton, MD Surrey diagnostic techniques mentioned. I Salmon Arm have come across some patients spend- Med student ing hundreds of dollars for blood tests The bags we use are biodegradable ordered by and sent away to US labo- and compostable. We pay a slight pre- journal launched ratories by some of these practition- mium for this feature, but think that t is with great excitement that ers. Many reports show numerous pos- you will agree that it’s worth it.—ED we announce the first edition of itive results not validated by patients the UBCMJ! The University of or physicians. IBritish Columbia Medical Jour- With regard to colonic irrigation, Prenatal genetic nal is a student-run, peer-reviewed there is an interesting article on colon screening academic journal. Currently, over 100 therapy and related on students at UBC from all levels and www..com. he BC Perinatal Health Pro- training and three distributed sites are We should always have an open gram has unveiled its new involved in as writers, artists, review- mind to any complementary and alter- TPrenatal Genetic Screening ers, editors, layout designers, and ex- native medicine. However, we should Program, with mailings of an algo- ecutive directors. The UBCMJ accepts never lose sight of evidence-based rithm and pamphlets to be handed out articles in all areas of medicine, inclu - approaches in the diagnosis and man- to patients. ding research, reviews, case reports, agement of our patients. The program is very good, with medical history, ethics, medical an - —H.C. George Wong, MD an algorithm that is clear and easy to thropology, epidemiology, public Vancouver follow. The recommendation with health, and international health. The nuchal translucency (NT), however, I UBCMJ also features original artwork References believe, puts us practitioners in a very and photography created by medical 1. Bennett JE. Searching for the yeast con- awkward medicolegal position. The students as its cover art. With finan- nection. N Engl J Med. 1990;323:1766- protocol directs that NT be recom- cial support from the CME, the 1767. mended for pregnant women aged 35 BCMA, the UBC Faculty of Medi- 2. Candidiasis hypersensitivity syndrome. to 39 “if available.” However, when a cine, and the UBC Medical Under- Executive Committee of the American requisition is submitted under such graduate Society, the UBCMJ is avail- Academy of Allergy and Immunology. J circumstances to either the BC Wo - able in print and online. Allergy Clin Immunol. 1986;78:271-273. men’s Hospital or Surrey Memorial Please join us in celebration of our 3. Dismukes WE, Wade JS, Lee JY, et al. A Hospital (I have not canvassed other launch on 8 September 2009 at the randomized, double-blind trial of nystatin hospitals), the requisition is rejected Life Sciences Centre, UBC. E-mail therapy for the candidiasis hypersensitiv- citing “clinical situation does not meet [email protected] if you are inter- ity syndrome. N Engl Med. 1990;323: criteria.” I understand that NT need ested in submitting student writing or 1717-1725. not be offered if the test is not avail- placing an advertisement. Check out 4. Quackwatch. Dubious “yeast allergies.” able. However, in such instances, the our web page at www.ubcmj.com for www.quackwatch.org/01QuackeryRelat aforementioned hospitals should issue information on how to get involved edTopics/candida.html (accessed 21 statements that NT is not available. with our second edition, and to down- May 2009). Otherwise, the implication is that it is load our first edition (available Sep- available. In such a case, for us to not tember 2009). Another unwanted recommend it would expose us to —Pamela Verma, BSc (Hons) medicolegal difficulties in the unfor- —Diane Wu, BSc (Hons) plastic bag tunate (albeit maybe rare) circum- Editors in Chief he plastic bag covering the stance that a positive case is not picked —Ciara Chamberlain, MSc May 2009 BCMJ has just sent up by a Serum Integrated Prenatal —Bez Toosi, BSc Tme over the edge. We cannot Screen. On the other hand, if we Communications Editors

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