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If you buy metronidazole, you are assured that you will be able to treat the bacterial infection you have developed.  However, you cannot buy metronidazole over-the-counter because you need a medical prescription to buy metronidazole.  Without any medical prescription, the pharmacist will not dispense and allow you to buy metronidazole.  These days, antibiotics have strictly become prescription drugs only due to the abuse that some people have done.  This is why if you were to have any type of bacterial disease, your only option in being able to buy metronidazole is to visit your doctor and have your issue diagnosed.  If your doctor believes you need to buy metronidazole as antibiotic treatment, you will be given prescription to buy metronidazole.

There are two ways to buy metronidazole.  You can buy metronidazole at your local pharmacy or you can buy metronidazole online.  A lot of people actually buy metronidazole online these days as they are able to get lots of savings.  The prices of metronidazole at online shops simply cannot be matched by a physical shop since online shops do not have to pay a lot of dues and permits just to be able to sell.  The low price of metronidazole is actually what draws most people who need to use metronidazole to buy metronidazole online. Read more…

What's in the news: Dec. 24 -- Holiday analgesia

Canadian Medicine will return on Monday, January 5.

Edmonton is suffering from a series of outbreaks of norovirus in hospitals, nursing homes and child-care centres, according to a health advisory released yesterday by Alberta Health Services. There have been 20 outbreaks in the city in December. Associate medical officer Dr James Talbot said the holidays could help spread the virus. "It’s a time," he cautioned, "when people get together in groups and they serve food."

CMA]

Giving statins to patients before they undergo heart surgery reduces the risk of their developing post-op delirium from 20% to 13%, write a multidisciplinary team of University of Toronto and German researchers in an article to be published in next month's issue of Anesthesiology. "[T]o the best of our knowledge," they write, "this is the first report identifying an association between preoperative statin therapy and postoperative delirium in a cardiac surgical population. A double-blind, randomized, placebo-controlled clinical trial would be required to validate these findings."

Just as many Ontario general surgeons consult the internet for information on medical evidence and guidelines as consult their colleagues. [ (PDF)]

Vasovagal syncope may have a genetic origin, suggest two University of Calgary researchers in an article to be published next month.

The Toronto Star examined the language barrier between immigrants and their doctors. [Toronto Star]

Innovation Canada, a government-funded science research funding body, put together its list of the coolest research in 2008. The list includes bionic arms, a CPR glove, and more.

After Dr Stephen Harley, of Dartmouth, Nova Scotia, was found to have prescribed drugs for himself, he had restrictions posed on his licence to practise and lost his narcotics prescription permit. At a College of Physicians and Surgeons of Nova Scotia disciplinary hearing earlier this month "Dr. Harley immediately acknowledged he had been diverting prescription medication for his own personal use." [CPSNS decision (PDF)]

When I get emails with titles like "Penis Extender Certified by Canadian Health Authorities" I typically hit MARK AS SPAM right away. But when "Penis Extender Certified by Canadian Health Authorities" arrived today, it looked halfway reputable. It turned out not to be spam at all, but rather the announcement that the Andropenis, a frightening-looking "penile traction device" that promises 3-4 cm more length, has been certified by the Canadian Medical Devices Conformity Assessment System. The Andropenis also has some more traditional medical indications, for the treatment of Peyronie's disease and to reduce post-operative scar retraction. I couldn't find the original documentation on the certification, so I guess we'll have to take the makers of Andropenis at their word for now. Unless perhaps I've been taken in by a particularly effective spammer...

A new product called Diet Coke Plus -- cola infused with some vitamin B, zinc, niacin and magnesium, which is being marketed as "Diet Coke with Vitamins & Minerals" -- has got the US Food and Drug Administration's hackles up. The FDA informed Coca-Cola this month that its new Plus drink's name violates the law. Diet Coke Plus "makes a nutrient content claim but does not meet the criteria to make the claim," the FDA said, adding that the regulatory agency "does not consider it appropriate to fortify snack foods such as carbonated beverages." "If the label says it's healthy then it must be true," snickered Forbes's Lisa LaMotta.

Sai-Man Tang, an Ontario man studying medicine in England, has been sentenced to one year in jail for importing child pornography. Justice Roydon Kealey called his case "most tragic and difficult criminal case" he'd ever heard, given Mr Tang's academic excellence in England and at Harvard, where he was doing graduate work.

Perennial failed US presidential candidate Ralph Nader will speak at the University of Toronto on January 30 on the subject of "importance of a publicly funded health care system and the importance of preservation of Canada’s jewel of a system." Tickets are $19.62, in memory of the year Mr Douglas set up Canada's first universal, publicly funded healthcare system in Saskatchewan.

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What's in the news: Dec. 23 -- The world's most unhealthy burger

An outraged Dr Yoni Freedhoff, the Ottawa obesity specialist who blogs at Weighty Matters, describes Disney's latest accomplishment: the creation of the "world's vilest burger," a cheeseburger squished between two miniature pizzas instead of a bun. I respectfully dissent, and would like to submit for Dr Freedhoff's consideration the Luther Burger (named after the musician Luther Vandross), which features a bacon cheeseburger on a grilled, sliced glazed donut. [Photo from ] Another good candidate for the title of world's most unhealthy burger is the deep-fried cheeseburger.

Family physicians' "lifestyle interventions" -- which translates to telling patients to get some exercise, don't eat too much junk food, etc. -- don't appear to do much good for patients at low risk of cardiovascular problems. "In general, while it is difficult to suggest that primary care providers not counsel all their patients on healthy lifestyles, their time might be better spent focusing on those at higher risk," found a pair Newfoundland researchers, in their systematic review published this month. [Canadian Family Physician]

A former president of the College of Physicians and Surgeons of Alberta was killed over the weekend when her husband's plane crashed in Colorado. Family physician Sheila Malm, whose husband, oil company consultant Gerrit Maureau, was flying, was 65. "There are some people who wake up in the morning and just give all day," Dr Juliet Guichon, a senior associate in the University of Calgary's bioethics office, where Dr Malm used to work as well, told the Calgary Herald. "When she saw a patient, she worked hard to see the patient in a complex web of relationships, rather than seeing the patient as an isolated human. That's how you give better care."

Health Canada has issued a safety warning about the increasingly common off-label use of the cancer drug bevacizumab (Avastin) to treat age-related macular degeneration by injecting it directly into patients' eyes. The warning, which reminds doctors that the drug was never evaluated for use in the eyes, said, "As of November 26, 2008, Roche has been made aware of 25 spontaneously reported Canadian cases of eye inflammation, endophthalmitis, blurred vision, and floaters, some of which have been described as Toxic Anterior Segment Syndrome (TASS), in patients who were administered aliquots of AVASTIN Lot B3002B028 intravitreally." [Health Canada MedEffect]

A recent labour-mobility agreement between the medical regulatory bodies in Quebec and Ontario has some authorities on the Quebec side of the border concerned that doctors are going to see greener grass in Ontario. Some specialists could earn up to 30% more in Ontario than they do in Quebec.

In the wake of the death by freezing of André Gagnon, a homeless man, in Montreal, Quebec Health Minister Dr Yves Bolduc has been put on the defensive on the question of the amount of funding the provincial government contributes to homeless shelters. [La Presse] Montreal shelters receive $12 per bed per night from Quebec, whereas Toronto shelters receive $61 from Ontario, according to the head of Montreal's Old Brewery Mission shelter, where Mr Gagnon was last seen before he died. "We invest four times more than was invested in 2003 for shelters," Dr Bolduc told La Presse. "The condition of the homeless is something that we have been concerned with but we are waiting for the results of a parliamentary commission to decide on our action plan." Dr Bolduc also disagreed with the comparison with Toronto. Meanwhile, $24 million in new funding was announced Tuesday to combat poverty in Montreal, but some people were disappointed that none of the money was dedicated to homeless shelters.

Too many young Quebec GPs are starting their careers working in hospitals and emergency departments instead of walk-in clinics, to the detriment of the healthcare system, according to a new report from the Quebec Federation of General Practitioners. "That newly graduated physicians would want to work in emergency, that is not surprising," said report co-author Isabelle Paré. "They're young and emergency gives them an adrenaline rush. What's more disturbing is that after three years [of practice], more of them are in second-line care, in the hospital. If that trend continues, we'll have a shortage in first-line care." [Le Soleil]

The hypothesis: "The discordance between fertility intentions and outcomes may be associated with mental health in the general population." In other words, unintended pregnancies and childlessness are both real bummers. But when two McGill researchers examined the data, it turned out that neither of those outcomes caused women psychological distress, and only the former caused distress in men.

Saskatchewan researchers have produced the first diffraction-enhanced imaging (DEI) soft-tissue X-rays ever in North America.

Someone was bound to do it eventually. A Californian researcher replicated the infamous Stanley Milgram obedience experiment in which subjects were instructed to administer higher and higher voltage shocks, which they believed falsely to be real, to other subjects, in order to test their willingness to obey the instructions of the fake study's investigators. The man who has reproduced it, Jerry Burger, however, did not take it as far as Dr Milgram did. Dr Burger did not allow his subjects to administer a fake shock after it became clear the fake patient would suffer. "It was a very, very, very stressful experience for many of the participants," he said of the original study. "That is the reason no one can ethically replicate the experiment today." Dr Burger found that 70% of participants were willing to increase the voltage of a shock to the patient when asked to do so, even after seeing the patient (an actor) scream in pain. "That was surprising and disappointing," he said. Read more about Dr Milgram's obedience experiment.

In a new video, Dr Jock Murray, the former Dalhousie University dean of medicine, gave his take on the good and bad aspects of the Canadian and American healthcare models. "Canada gives everything to everyone, but in some instances, not right now. The USA gives everything right now, but not to everyone."

The holiday edition of Grand Rounds was published Tuesday.

Most popular posts of 2008

In 2008, Canadian Medicine was visited more than 57,000 times. These were the 10 most popular articles over the past year:

1. THE INTERVIEW: Dr Mehmet Oz
"I don’t think the gentlemanly approach always works. You have to shake some people up. The reason for that is that our biggest enemy in educating people about their bodies in Canada and in America, is that they think they already know the answers. And they don’t." ... On Oprah’s heart: "She has a beautiful heart. It’s pristine. It has no blockages and functions very elegantly."

2. Grand Rounds 4:25
Sultry nurses seduce patients; training to become a doctor is akin to learning to sign opera; and the best hospital cafeteria in Canada, with caribou stew on the menu. (No kidding.)

3.
Was it the vapours? Acute Darcyitis? A bilious attack?

4. Canada's greatest medical research
Canada has produced a disproportionately large number of major biomedical breakthroughs. This report exhaustively catalogues the best of the best. You probably knew about Dr Frederick Banting's discovery of insulin, but you're sure to be surprised at some of the high-profile research mentioned in the report, like robot surgeons, music therapy for the physically disabled, induced hypothermia for heart surgery patients and "cobalt bombs," to name a few of the most interesting items.

5. Vasectomies by Dr Dick Chopp, and more physician aptonyms
Dr Richard "Dick" Chopp performs vasectomies at a urology practice in Austin, Texas. He even gives out T-shirts to vasectomy patients. On the back, they read "I was 'chopped' at the Urology Team." Classy... Dick Chopp isn't the only doctor with a medically appropriate (or inappropriate, as the case may be) moniker -- there are plenty more, including a few Canadians as well.

6. Q&A: Why tech journalist just had to try body modification
San Francisco journalist Quinn Norton had a magnet implanted into her fingertip. "When my GP asked why I'd had it done, I told him it was to get a sense for electro magnetic fields, live wires, spinning motors, and the like. He asked me why I'd want that? I was at a loss. I wasn't sure how to explain it, other than to say, why wouldn't you want a completely new sixth sense?"

7. Vancouver Island plans clean crack pipe program after new study shows need
Coinciding with the release of a new study from the University of Victoria that found hepatitis C can be transmitted on shared crack pipes, the Vancouver Island Health Authority has announced it will provide clean crack pipe mouthpieces and filters to addicts at needle exchange sites beginning April 1, 2008.

8. Is universal healthcare an illegal, dangerous monopoly? One Ontario lawsuit argues 'yes'
Adolfo Flora, whose first legal appeal in his case against the government-operated Ontario Health Insurance Plan (OHIP) was dismissed last year, is back at it again. His lawyers insist that Ontario's universal healthcare system is putting citizens' lives in danger. (OHIP provides universal healthcare insurance; OHIP has a monopoly over healthcare insurance; monopolies are detrimental to the public good; ergo OHIP is detrimental to the public good -- so goes Mr Flora's argument.)

9. Doctors must kill the skunk, says bioethicist
When Toronto neurosurgeon and bioethicist Mark Bernstein encountered a wounded skunk in the middle of the road on his drive to work, he considered his options. "I figured I had four: 1) I could stop and pick it up and drive to an all-hours veterinary clinic (I knew the whereabouts of one due to a recent illness in one of my two Labradors); 2) I could keep driving and forget about it; 3) I could call 911 or information to get a number for the humane society (assuming they have an after-hours number); and 4) I could try to somehow put the poor thing out of its misery." You can probably guess where this story is going.

10. THE INTERVIEW: Dr Brian Goldman, host of the CBC radio show White Coat, Black Art
"We devoted a half a show to whether a real-life House would be able to practise medicine in the real world... Probably 10 or 15 years ago he would have been able to, but now that doctor would be put out on his ass pretty quickly. I’ve heard of a surgeon who flung scalpels at OR nurses. You’re not allowed to do that anymore."

What's in the news: Dec. 22 -- Christmas gift packaging injuries

A round-up of Canadian health news, from coast to coast to coast and beyond, for Monday, December 22.

Plastic Christmas-gift packaging every year results in hospital admissions for lacerations and puncture wounds on Christmas Day every year. "That clamshell packaging is absolutely diabolical," said Colorado emergency physician David Ross. Another potential packaging-related diagnosis: "wrap rage."

A group of 18 Newfoundland and Labrador specialist physicians has gone public with concerns about the province's inability to retain and recruit medical specialists to the province. The 18 physicians were excluded from wage increases offered recently to certain specialists. "The only way you're going to get more people like us is to ante up a little, unfortunately," Mark Stefanelli, a neurologist, told The Telegram. They want a 35% raise, instead of the 20% they expect to receive.

This flu season is presenting problems for public officials: some flu viruses have been found to be oseltamivir-resistant while others are amantadine- and rimantadine-resistant. None of the common strains appear to be resistant to zanamivir, though that drug is contraindicated in children under seven and some adult patients. For more information on this year's flu virus drug resistance and current trends, see the latest FluWatch from the Public Health Agency of Canada. [PHAC]

Maple Leaf Foods agreed to an out-of-court settlement with patients who had initiated class-action lawsuits against the company after an outbreak of listeriosis killed at least twenty Canadians earlier this year and infected many more. The total amount of the settlement is between $25 million and $27 million, with individual payouts ranging from $750 for a one- or two-day-long illness to more than $200,000 for the families of people who died as a result of their infections. [Toronto Star] Before the 2008 listeriosis scare, 6% of Canadians said they would not eat deli meats; after, that figure jumped to 39%, according to University of Guelph researchers.

Two cases of flesh-eating disease, or necrotizing fasciitis, around the bellybuttons of Alberta infants born a day apart this summer were not connected, an internal review concluded. One of the babies died.

One of the most effective ways to control the spread of HIV in prisons is to provide a needle exchange program and opioid substitution therapy, a Quebec consultant reported in the January 2009 issue of The Lancet Infectious Diseases. The Conservative government last year decided not to follow the advice of the Public Health Agency of Canada to institute a Prison Needle Exchange Program.

Alberta's Ministry of Health and Wellness is projected to run a $1.3 billion deficit over the next year. "They're always the large elephant in the room," said Premier Ed Stelmach of the ministry. "It just seems like every area we deal with, when we take a look at it... quite frankly you could do it another way that makes it more efficient," said Health Minister Ron Liepert of a recent report intended to save money in the province's healthcare system. Mr Liepert's planned reforms got a ringing endorsement from the Calgary Sun's Rick Bell, who declared in his headline, "The only physicians who have to fear Health Minister Ron Liepert are the spin doctors -- all he wants is to make the system run better". Mr Bell was impressed with Mr Liepert's honesty that the public healthcare system may not be able to cover everything. "There is no plan at this stage for us to not cover something in the future," Mr Liepert told him. "But I'm reviewing everything. It would be irresponsible for us not to look at all aspects of the health system. That review needs to take place. For every dollar we spend, are we certain we need to spend it? I have to ensure the dollars I ask for are justified." Mr Liepert also chatted with the Edmonton Journal, for the paper's long, in-depth profile of him. In case you haven't heard him say it enough yet, he's sick and tired of consultations and studies. "You assess the pros and cons and make a bloody decision," he declared. "Ralph Klein did all sorts of consultations... How much success did they have? How much did health care change under Ralph Klein? So why would we follow the same path he did and get the same results?"

Charges for attempted murder have been brought against an 18-year-old who shot a man at the front entrance of a Halifax hospital last month.

Private prescription drug insurance plans, as exist in most of Canada, result in inequitable care provided by physicians in the public system, reported a new study by McMaster University economics and epidemiology professor Jeremiah Hurley and London School of Economics researcher Sara Allin in Health Economics. In another article, this time with the Mental Health Commission of Canada's Gillian Mulvale, Dr Hurley found that Canadian mental health patients without private drug insurance plans were less likely to be receiving pharmaceutical treatment for their illness.

Leslie Iwerk's Oscar-nominated short documentary, Downstream, has upset Alberta Minister of Culture Lindsay Blackett. The film, whose central character, family physician John O'Connor, was intimidated and investigated after he reported a cluster of unusual cancers near the oil-sands industrial developments in northern Alberta, received a $67,000 grant from the province. Mr Blackett claimed he didn't know the film's subject when the grant was approved; if he had, he told CBC News, he might not have given out the money. "[W]e're looking at now how do I get more information about it because — oh, it's a film about Alberta, it's a film about the oilsands — but who knew what it meant at the time?" Displaying a phenomenally questionable understanding of the role of arts grants, Mr Blackett explained, "Because if I'm going to actually invest money on behalf of Albertans into a film, the whole idea is to show Alberta in a better light, to create an economic diversification to help them, so anything that's going to be negative is only going to be a negative impetus on this province." He quickly renounced that position, resorting to the tried and true excuse that his quotes were taken out of context. "There is no provision now for any type of control over content, and we have no plans to institute any control over content," he told Fort McMurray Today. [Downstream is] "one of hundreds of different films that get produced, and we’ve got to have thicker skin," he said. I wrote about Downstream and Dr O'Connor in October. [Canadian Medicine]

Nicole Eaton, the director of the St Michael's Hospital Foundation, and Irving Gerstein, the former chair of the Mount Sinai Hospital board, are Prime Minister Stephen Harper's two new Senate appointments in Ontario. Mr Harper appointed 16 other people to the Senate across the country, including journalists Mike Duffy and Pamela Wallin. [Maclean's]

Physicians at the Toronto General Hospital performed the world's transplant of lungs repaired while outside of the donor's or recipient's bodies. Their methodology could "easily double or triple the number of [donor] lungs used today," said Dr Shaf Keshavjee.

The New Brunswick government met with the province's nursing association to work on a strategy to attract foreign nurses.

A faster heart rate and breathing rate can predict post-traumatic stress disorder, a team of Australian psychiatrists wrote in last month's Journal of Clinical Psychiatry. Reducing "acute arousal immediately after trauma... may limit PTSD development in some individuals," they suggested.

British scientists screened a bunch of embryos and chose one that didn't hold a gene that could predispose the child to breast cancer. The baby is due to be born next week.

"Now all they need in universal death care," snickered Milwaukee columnist Patrick McIlheran after he read about the patient who died in a Montreal walk-in clinic's waiting room after nobody attempt to perform resuscitation. "That happened in Quebec, where they do have universal, government-supported health care for all... It’s just, of course, that there’s no guarantee you’ll get any in time." But one blogger reminded Mr McIlheran that that the doctor in question, Jacques Chaoulli, is in fact opted out of the province's public healthcare system. "That's right," wrote Illusory Tenant. "McIlheran has selected the alleged negligence of a physician that derives his livelihood from U.S.-style private insurance plans as an example of how bad a public health care system is." You can read my earlier coverage of the case if you missed it before. [Canadian Medicine]

Why was a longtime Manitoba family medicine leader suddenly let go?

Dr Larry Reynolds, a senior member of the University of Manitoba family medicine faculty and the Winnipeg Regional Health Authority management, was surprised to be informed in October that his contract with both organizations would not be renewed.

But why? Even Dr Reynolds hasn't been told. As he, along with the Canadian Association of University Teachers and a handful of Manitoba activists and journalists, presses for answers from the government, several competing theories have emerged:

1. He didn't get on board with the health authority's agenda. He voiced his opposition to the government's 2004 decision to close the low-risk obstetrics ward at the Victoria General Hospital, in Winnipeg, and for "speaking out about the concerns of family doctors." (He was scolded by his employers for writing a letter to the Winnipeg Free Press about the province's family medicine policies.) This is the theory . "I may have offended some people by speaking strongly about something I feel strongly about," he CBC News. It is supported, in part, by Winnipeg Regional Health Authority vice-president Dr Brock Wright: "He did have a tendency sometimes to take his concerns directly to the minister, directly to the government, without letting us know in advance that he was doing so," the Winnipeg Free Press . "That's not really appropriate for someone in an administrative role -- they're expected to bring their concerns right to us." Manitoba Liberal Party leader Jon Gerrard, a physician himself, has spoken out publicly to criticize the university for not giving Dr Reynolds tenure and the freedom to voice his opinions freely -- going as far as calling the situation a government "ban on free speech" -- and the Canadian Association of University Teachers has established an ad hoc investigatory committee to "look into allegations that Dr. Larry Reynold’s academic freedom and the University’s policies on 'Appointment of Heads of Departments' were violated in the recent head selection process in family medicine."

2. He was, plain and simple, a bad boss. He "inappropriately delegated tasks and made disrespectful comments about his subordinates," Dr Wright the Free Press. Performance reviews showed that he was not a "team player" and had leadership problems, . "Wright said one of the family doctor's subordinates retired from her administrative role early because she had trouble working with him," reported the Free Press, "and a number of people complained that Reynolds breached the WRHA's respectful workplace policy... Wright claimed Reynolds inappropriately delegated tasks, and made disrespectful comments about his subordinates."

3. The institutional criticism wasn't the real problem -- it was his opinions on medical ethics. "Univ. of Manitoba: Giving the Boot To Pro-Life Doctors," read the headline above a by Social Conservatives United director John Pacheco. "In what was obviously a politically motivated decision," Mr Pacheco wrote, "the University of Manitoba has shown its intolerance and bigotry against a renowned and experienced professor and doctor because he did not tow the politically correct pro-abortion and pro-establishment line regarding family medicine." According to Social Conservatives United's , Dr Reynolds was a contributor to "pro-life" publications and sat on the editorial board of the Canadian Physicians for Life newsletter. There were rumours as well, the blog article said, that he may have clashed with the University of Manitoba in 2003 and 2004 when a med student was denied his degree because he said he would not refer patients for abortions. Dr Reynolds , "Physicians must be able to maintain their integrity and consciences and to decline to participate in care that they reasonably believe to be harmful to the patient or to others. To do otherwise would herald the twilight of medicine as a noble and compassionate profession."

If we choose to believe Dr Wright's stated reasons for not extending Dr Reynolds's contract, the answer is some combination of #1 and #2. But for the social conservative group, which appears to be predisposed to conspiracy theories, the real menace is the possibility that #3 is what sparked the decision to get rid of Dr Reynolds, and that #1 and #2 have only been trotted out publicly as a pretense. It is telling, however, that Dr Reynolds has not suggested in any of his statements so far that #3 has any merit.