Table of Contents

April 20, 2004; 140 (8)

Articles

  • Excluding a diagnosis from consideration requires a test result that will reduce its probability to below a threshold. Among tests for d-dimer, enzyme-linked immunosorbent assays (ELISAs) had the highest sensitivity and lowest negative likelihood ratio, which makes ELISA the best d-dimer test for excluding deep venous thrombosis and pulmonary embolism.

  • Alcohol intake, measured at one point in time, is associated with a modest relative elevation in colorectal cancer rate. This effect occurs mainly at the highest levels of alcohol intake.

  • During an outbreak in Hong Kong, the authors searched for subclinical or mild forms of severe acute respiratory syndrome (SARS) coronavirus infection. They found no evidence for widespread occurrence of a mild form of SARS that would escape detection when patients present for clinical evaluation.

Reviews

  • Focusing on early induced abortions, the authors describe the numbers and characteristics of women having abortions, review the methods used, summarize safety data, explain how internists can respond to patients' requests for referral to abortion providers, and describe costs.

  • In the last several years, Alzheimer disease researchers have come to agree that certain biochemical changes in the hippocampus and association cortices occur many years or decades before clinical symptoms. We can now describe a rough outline of the cascade of events leading to disease.

Perspectives

  • Today's chaotic health care scene gives general internal medicine an opportunity to innovate and move beyond its current state of confusion. The field must adapt to a new world of consumerism, rising public expectations, widespread information dissemination, and pressures to hold down costs at a time when the demand for services is increasing because more people are surviving to live with chronic disease in old age.

Clinical Guidelines

  • The American College of Physicians makes 4 recommendations for lipid control in patients with type 2 diabetes: 1) Use lipid-lowering therapy for secondary prevention of cardiovascular mortality and morbidity for all patients with known coronary artery disease and type 2 diabetes; 2) use a statin for primary prevention of macrovascular complications in patients with type 2 diabetes and other cardiovascular risk factors; 3) patients with type 2 diabetes who take statins should take at least moderate doses; 4) for patients with type 2 diabetes who are taking statins, routine monitoring of liver function tests or muscle enzymes is unnecessary except in specific circumstances.

  • In patients with type 2 diabetes, treatment with lipid-lowering agents reduces the risk for cardiovascular disease. Statins reduce cardiovascular disease risk in most patients, including those whose baseline low-density lipoprotein cholesterol levels are below 2.97 mmol/L (<115 mg/dL), and possibly below 2.59 mmol/L (<100 mg/dL). Most patients with diabetes should receive at least moderate doses of these drugs.

Editorials

  • We hope that the report by the Society of General Internal Medicine Task Force on the Domain of General Internal Medicine in this issue will spur conversations among internists and their colleagues, patients, and others with a vested interest in seeing health care safely through dangerous waters. To start those conversations, we have asked 5 individuals to respond to different aspects of the report.

  • I agree with the thrust of the Society of General Internal Medicine Task Force report, but it left out an essential feature of daily practice: We connect, interpret, personalize, and customize medical care.

  • The combined force of all generalists who care for adults (internists and family physicians) could collectively speak with a much more powerful voice to address the critical issues about the important role of primary care in the health care system.

  • The Society of General Internal Medicine Task Force on the Domain of General Internal Medicine has reaffirmed that breadth and depth is the fundamental strength of internal medicine.

  • The Task Force's proposals for payment reform will fall on deaf ears if they increase the total costs of care. Evidence to the contrary is essential.

  • The Task Force recommends using residency training to prepare for the requirements of a specific practice: subspecialist or generalist, rural or urban, and predominantly outpatient or inpatient setting. I concur, but with reservations.

Letters

Medical Writings: Book Notes

Current Clinical Issues

Book Listings

Medical Notices

Summaries for Patients