Main CURRENT Medical Diagnosis and Treatment 2012

CURRENT Medical Diagnosis and Treatment 2012

, ,
The #1 annually updated text in internal medicine! Includes 6 online-only chapters at no additional cost! Go to: www.AccessMedicine.com/CMDT The book that puts the latest research where it belongs . . . into your practice Written by clinicians renowned in their respective fields, CMDT offers the most current insight into symptoms, signs, epidemiology, and treatment for more than 1,000 diseases and disorders. For each topic, you’ll find concise, evidence-based answers to questions about hospital and ambulatory medicine. This streamlined clinical companion is the fastest and easiest way to keep abreast of the latest medical advances, prevention strategies, and cost-effective treatments. Features and content critical to clinical practice: Strong emphasis on the practical aspects of clinical diagnosis and patient management in all fields of internal medicine Full review of all internal medicine and primary care topics, including gynecology and obstetrics, dermatology, neurology, ophthalmology, geriatrics, and palliative care The only text with an annual review of advances in HIV treatment Specific disease prevention information Drug treatment tables, with indexed trade names and updated prices – plus helpful diagnostic and treatment algorithms Recent references with PMID numbers Six online-only chapters available at no additional cost Full-color photographs and illustrations NEW TO THIS EDITION: New chapter on Sports Medicine & Outpatient Orthopedics Extensive revision of medical and surgical conditions of pregnancy Updated coverage of evaluating fertility in women, immunization requirements, and the use and safety of nonsteroidal and anti-inflammatory drugs Extensive revision of Kidney Disease chapter New topics include snoring a selection of common musculoskeletal problems such as subacromial impingement syndrome, rotator cuff tear, anterior cruciate ligament and meniscus injuries, patellofemoral pain syndrome, and inversion and eversion ankle sprains New online-only chapter on Women’s Health Issues S.I. units used throughout Visit CMDT2012.com or join the conversation at #CMDT
Year: 2011
Edition: 51
Publisher: McGraw-Hill Medical
Language: english
Pages: 1867
ISBN 10: 0071767649
ISBN 13: 9780071767644
Series: Lange Current
File: MOBI , 22.85 MB
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CURRENT Medical Diagnosis and Treatment 2012

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Contents




Authors

Preface





1. Disease Prevention & Health Promotion

Michael Pignone, MD, MPH, & René Salazar, MD



Prevention of Infectious Diseases



Prevention of Cardiovascular Disease



Prevention of Osteoporosis



Prevention of Physical Inactivity



Prevention of Overweight & Obesity



Cancer Prevention



Prevention of Injuries & Violence



Prevention of Substance Abuse: Alcohol & Illicit Drugs





2. Common Symptoms

Ralph Gonzales, MD, MSPH, & Paul L. Nadler, MD



Cough



Dyspnea



Hemoptysis



Chest Pain



Palpitations



Lower Extremity Edema



Fever & Hyperthermia



Involuntary Weight Loss



Fatigue & Chronic Fatigue Syndrome



Acute Headache



Dysuria





3. Preoperative Evaluation & Perioperative Management

Hugo Q. Cheng, MD



Evaluation of the Asymptomatic Patient



Cardiac Risk Assessment & Reduction



Pulmonary Evaluation in Non–Lung Resection Surgery



Evaluation of the Patient with Liver Disease



Preoperative Hematologic Evaluation



Neurologic Evaluation



Management of Endocrine Diseases



Kidney Disease



Antibiotic Prophylaxis of Surgical Site Infections





4. Geriatric Disorders

C. Bree Johnston, MD, MPH, G. Michael Harper, MD, & C. Seth Landefeld, MD



General Principles of Geriatric Care



Assessment of the Older Adult



Management of Common Geriatric Problems



Dementia



Depression



Delirium



Immobility



Falls & Gait Disorders



Urinary Incontinence



Undernutrition & Frailty



Pressure Ulcers



Pharmacotherapy & Polypharmacy



Vision Impairment



Hearing Impairment



Elder Abuse





5. Palliative Care & Pain Management

Michael W. Rabow, MD, & Steven Z. Pantilat, MD



Definition & Scope of Palliative Care



Pain Management



Principles of Pain Management



Pain at the End of Life



Pharmacologic Pain Management Strategies



Nonpharmacologic Treatments



Palliation of Other Common Symptoms



Dyspnea



Nausea & Vomiting



Constipation



Delirium & Agitation



End-of-Life Care



Tasks after Death





6. Dermatologic Disorders

Timothy G. Berger, MD



Principles of Dermatologic Therapy



Common Dermatoses



Pigmented Lesions



Scaling Disorders



Vesicular Dermatoses



Weeping or Crusted Lesions



Pustular Disorders



Erythemas



Blistering Diseases



Papules



Violaceous to Purple Papules & Nodules



Pruritus (Itching)



Inflammatory Nodules



Epidermal Inclusion Cyst



Photodermatitis



Ulcers



Miscellaneous Dermatologic Disorders



Pigmentary Disorders



Baldness (Alopecia)



Nail Disorders



Dermatitis Medicamentosa (Drug Eruption)





7. Disorders of the Eyes & Lids

Paul Riordan-Eva, FRCS, FRCOphth



Refractive Errors



Disorders of the Lids & Lacrimal Apparatus



Conjunctivitis



Pinguecula & Pterygium



Corneal Ulcer



Acute Angle-Closure Glaucoma



Chronic Glaucoma



Uveitis



Cataract



Retinal Detachment



Vitreous Hemorrhage



Age-Related Macular Degeneration



Central & Branch Retinal Vein Occlusions



Central & Branch Retinal Artery Occlusions



Transient Monocular Blindness



Retinal Disorders Associated with Systemic Diseases



Ischemic Optic Neuropathy



Optic Neuritis



Optic Disk Swelling



Ocular Motor Palsies



Dysthyroid Eye Disease



Orbital Cellulitis



Ocular Trauma



Ultraviolet Keratitis (Actinic Keratitis)



Chemical Conjunctivitis & Keratitis



Treatment of Ocular Disorders



Precautions in Management of Ocular Disorders



Adverse Ocular Effects of Systemic Drugs





8. Ear, Nose & Throat Disorders

Lawrence R. Lustig, MD, & Joshua S. Schindler, MD



Diseases of the Ear



Diseases of the Nose & Paranasal Sinuses



Diseases of the Oral Cavity & Pharynx



Diseases of the Salivary Glands



Diseases of the Larynx



Tracheotomy & Cricothyrotomy



Foreign Bodies in the Upper Aerodigestive Tract



Diseases Presenting as Neck Masses





9. Pulmonary Disorders

Mark S. Chesnutt, MD, & Thomas J. Prendergast, MD



Disorders of the Airways



Pulmonary Infections



Pulmonary Neoplasms



Interstitial Lung Disease (Diffuse Parenchymal Lung Disease)



Disorders of the Pulmonary Circulation



Environmental & Occupational Lung Disorders



Pleural Diseases



Disorders of Control of Ventilation



Acute Respiratory Failure



Acute Respiratory Distress Syndrome





10. Heart Disease

Thomas M. Bashore, MD, Christopher B. Granger, MD, Patrick Hranitzky, MD, & Manesh R. Patel, MD



Congenital Heart Disease



Valvular Heart Disease



Coronary Heart Disease (Atherosclerotic CAD, Ischemic Heart Disease)



Disorders of Rate & Rhythm



Bradycardias & Conduction Disturbances



Congestive Heart Failure



Myocarditis & the Cardiomyopathies



Rheumatic Fever



Diseases of the Pericardium



Pulmonary Hypertension & Pulmonary Heart Disease



Neoplastic Diseases of the Heart



Cardiac Involvement in Miscellaneous Systemic Diseases



Traumatic Heart Disease



The Cardiac Patient & Surgery



Heart Disease & Pregnancy



Cardiovascular Screening of Athletes





11. Systemic Hypertension

Michael Sutters, MD, MRCP (UK)



How Is Blood Pressure Measured and Hypertension Diagnosed?



Prehypertension



Approach to Hypertension



Drug Therapy: Current Antihypertensive Agents



Resistant Hypertension



Hypertensive Urgencies & Emergencies





12. Blood Vessel & Lymphatic Disorders

Joseph H. Rapp, MD, Christopher D. Owens, MD, MSc, & Meshell D. Johnson, MD



Atherosclerotic Peripheral Vascular Disease



Nonatherosclerotic Vascular Disease



Arterial Aneurysms



Venous Diseases



Diseases of the Lymphatic Channels



Shock





13. Blood Disorders

Charles A. Linker, MD, & Lloyd E. Damon, MD



Anemias



Neutropenia



Leukemias & Other Myeloproliferative Disorders



Lymphomas



Stem Cell Transplantation



Blood Transfusions





14. Disorders of Hemostasis, Thrombosis, & Antithrombotic Therapy

Patrick F. Fogarty, MD, & Tracy Minichiello, MD



Platelet Disorders



Disorders of Coagulation



Antithrombotic Therapy





15. Gastrointestinal Disorders

Kenneth R. McQuaid, MD



Symptoms & Signs of Gastrointestinal Disease



Diseases of the Peritoneum



Diseases of the Esophagus



Diseases of the Stomach & Duodenum



Diseases of the Small Intestine



Diseases of the Colon & Rectum



Anorectal Diseases





16. Liver, Biliary Tract, & Pancreas Disorders

Lawrence S. Friedman, MD



Jaundice



Diseases of the Liver



Diseases of the Biliary Tract



Diseases of the Pancreas





17. Breast Disorders

Armando E. Giuliano, MD, & Sara A. Hurvitz, MD



Benign Breast Disorders



Fibrocystic Condition



Fibroadenoma of the Breast



Nipple Discharge



Fat Necrosis



Breast Abscess



Disorders of the Augmented Breast



Carcinoma of the Female Breast



Carcinoma of the Male Breast





18. Gynecologic Disorders

H. Trent MacKay, MD, MPH



Abnormal Premenopausal Bleeding



Postmenopausal Vaginal Bleeding



Premenstrual Syndrome (Premenstrual Tension)



Dysmenorrhea



Vaginitis



Cervical Polyps



Cyst & Abscess of Bartholin Duct Cervical Intraepithelial Neoplasia (Dysplasia of the Cervix)



Carcinoma of the Cervix



Leiomyoma of the Uterus (Fibroid Tumor)



Carcinoma of the Endometrium



Carcinoma of the Vulva



Endometriosis



Pelvic Organ Prolapse



Pelvic Inflammatory Disease (Salpingitis, Endometritis)



Ovarian Cancer & Ovarian Tumors



Polycystic Ovary Syndrome



Female Sexual Dysfunction



Infertility



Contraception



Rape



Menopausal Syndrome





19. Obstetrics & Obstetric Disorders

Vanessa L. Rogers, MD, & Kevin C. Worley, MD



Diagnosis of Pregnancy



Essentials of Prenatal Care



Nutrition in Pregnancy



Prevention of Rhesus Alloimmunization



Lactation



Travel & Immunizations during Pregnancy



Obstetric Complications of the First & Second Trimester



Vomiting of Pregnancy (Morning Sickness) & Hyperemesis Gravidarum (Pernicious Vomiting of Pregnancy)



Spontaneous Abortion



Recurrent (Habitual) Abortion



Ectopic Pregnancy



Gestational Trophoblastic Disease (Hydatidiform Mole & Choriocarcinoma)



Obstetric Complications of the Second & Third Trimester



Preeclampsia-Eclampsia



Acute Fatty Liver of Pregnancy



Preterm (Premature) Labor



Third-Trimester Bleeding



Obstetric Complications of the Peripartum Period



Puerperal Mastitis



Chorioamnionitis & Metritis



Medical Conditions Complicating Pregnancy



Anemia



Antiphospholipid Syndrome



Thyroid Disease



Diabetes Mellitus



Chronic Hypertensive Disease



Heart Disease



Asthma



Seizure Disorders



Infectious Conditions Complicating Pregnancy



Urinary Tract Infection



Group B Streptococcal Infection



Varicella



Tuberculosis



HIV/AIDS during Pregnancy



Maternal Hepatitis B & C Carrier State



Herpes Genitalis



Syphilis, Gonorrhea, & Chlamydia trachomatis Infection



Surgical Complications during Pregnancy



Cholelithiasis, Cholecystitis, & Intrahepatic Cholestasis of Pregnancy



Appendicitis



Carcinoma of the Breast



Ovarian Tumors





20. Musculoskeletal & Immunologic Disorders

David B. Hellmann, MD, MACP, & John B. Imboden, Jr., MD



Diagnosis & Evaluation



Degenerative & Crystal-Induced Arthritis



Pain Syndromes



Autoimmune Diseases



Vasculitis Syndromes



Seronegative Spondyloarthropathies



Infectious Arthritis



Infections of Bones



Other Rheumatic Disorders



Allergic Diseases



Atopic Disease



Primary Immunodeficiency Disorders





21. Electrolyte & Acid-Base Disorders

Kerry C. Cho, MD



Disorders of Sodium Concentration



Hyperosmolar Disorders & Osmolar Gaps



Disorders of Potassium Concentration



Disorders of Calcium Concentration



Disorders of Phosphorus Concentration



Disorders of Magnesium Concentration



Acid–Base Disorders



Fluid Management





22. Kidney Disease

Suzanne Watnick, MD, & Tonja Dirkx, MD



Assessment of Kidney Disease



Acute Kidney Injury (Acute Renal Failure)



Chronic Kidney Disease



Glomerular Diseases



Nephrotic Spectrum Disease in Primary Renal Disorders



Nephrotic Spectrum Disease from Systemic Disorders



Tubulointerstitial Diseases



Cystic Diseases of the Kidney



Multisystem Diseases with Variable Kidney Involvement





23. Urologic Disorders

Maxwell V. Meng, MD, FACS, Marshall L. Stoller, MD, & Thomas J. Walsh, MD, MS



Hematuria



Genitourinary Tract Infections



Acute Cystitis



Acute Pyelonephritis



Acute Bacterial Prostatitis



Chronic Bacterial Prostatitis



Nonbacterial Prostatitis



Prostatodynia



Acute Epididymitis



Interstitial Cystitis



Urinary Stone Disease



Male Erectile Dysfunction & Sexual Dysfunction



Male Infertility



Benign Prostatic Hyperplasia





24. Nervous System Disorders

Michael J. Aminoff, MD, DSc, FRCP, & Geoffrey A. Kerchner, MD, PhD



Headache



Facial Pain



Epilepsy



Dysautonomia



Sensory Disturbances



Weakness & Paralysis



Transient Ischemic Attacks



Stroke



Intracranial & Spinal Mass Lesions



Nonmetastatic Neurologic Complications of Malignant Disease



Pseudotumor Cerebri (Benign Intracranial Hypertension)



Selected Neurocutaneous Diseases



Movement Disorders



Dementia



Multiple Sclerosis



Neuromyelitis Optica



Vitamin E Deficiency



Spasticity



Myelopathies in AIDS



Myelopathy of Human T Cell Leukemia Virus Infection



Subacute Combined Degeneration of the Spinal Cord



Wernicke Encephalopathy



Stupor & Coma



Head Injury



Spinal Trauma



Syringomyelia



Degenerative Motor Neuron Diseases



Peripheral Neuropathies



Polyneuropathies & Mononeuritis Multiplex



Mononeuropathies



Bell Palsy



Discogenic Neck Pain



Brachial & Lumbar Plexus Lesions



Disorders of Neuromuscular Transmission



Myopathic Disorders



Periodic Paralysis Syndromes





25. Psychiatric Disorders

Stuart J. Eisendrath, MD, & Jonathan E. Lichtmacher, MD



Common Psychiatric Disorders



Substance Use Disorders (Drug Dependency, Drug Abuse)



Delirium & Other Cognitive Disorders (Formerly: Organic Brain Syndrome)



Psychiatric Problems Associated with Hospitalization & Illness





26. Endocrine Disorders

Paul A. Fitzgerald, MD



Diseases of the Hypothalamus & Pituitary Gland



Diseases of the Thyroid Gland



Diseases of the Parathyroids



Metabolic Bone Disease



Diseases of the Adrenal Cortex



Pheochromocytoma & Paraganglioma



Pancreatic & Duodenal Neuroendocrine Tumors



Diseases of the Testes & Male Breast



Amenorrhea & Menopause



Multiple Endocrine Neoplasia



Clinical Use of Corticosteroids





27. Diabetes Mellitus & Hypoglycemia

Umesh Masharani, MB, BS, MRCP(UK)



Diabetes Mellitus



Diabetic Coma



The Hypoglycemic States





28. Lipid Disorders

Robert B. Baron, MD, MS



Lipoproteins & Atherogenesis



Lipid Fractions & the Risk of Coronary Heart Disease



Therapeutic Effects of Lowering Cholesterol



Secondary Conditions that Affect Lipid Metabolism



Clinical Presentations



Screening for High Blood Cholesterol



Treatment of High Low-Density Lipoprotein Cholesterol



High Blood Triglycerides





29. Nutritional Disorders

Robert B. Baron, MD, MS



Protein-Energy Malnutrition



Obesity



Eating Disorders



Disorders of Vitamin Metabolism



Diet Therapy



Nutritional Support





30. Common Problems in Infectious Diseases & Antimicrobial Therapy

Peter V. Chin-Hong, MD, & B. Joseph Guglielmo, PharmD



Common Problems in Infectious Diseases



Fever of Unknown Origin



Infections in the Immunocompromised Patient



Health Care–Associated Infections



Infections of the Central Nervous System



Animal & Human Bite Wounds



Sexually Transmitted Diseases



Infections in Drug Users



Acute Infectious Diarrhea



Infectious Diseases in the Returning Traveler



Traveler's Diarrhea



Antimicrobial Therapy



Selected Principles of Antimicrobial Therapy



Hypersensitivity Tests & Desensitization



Immunization Against Infectious Diseases



Recommended Immunization of Infants, Children, & Adolescents



Recommended Immunization for Adults



Recommended Immunization for Travelers



Vaccine Safety





31. HIV Infection & AIDS

Andrew R. Zolopa, MD, & Mitchell H. Katz, MD



Epidemiology



Etiology



Pathogenesis



Pathophysiology



Clinical Findings



Differential Diagnosis



Prevention



Treatment



Course & Prognosis



When to Refer



When to Admit





32. Viral & Rickettsial Infections

Shruti Patel, MD, & Wayne X. Shandera, MD



Viral Diseases



Human Herpesviruses



Major Vaccine-Preventable Viral Infections



Other Neurotropic Viruses



Other Systemic Viral Diseases



Common Viral Respiratory Infections



Adenovirus Infections



Other Exanthematous Viral Infections



Viruses & Gastroenteritis



Enteroviruses that Produce Several Syndromes



Rickettsial Diseases



Typhus Group



Spotted Fevers



Other Rickettsial & Rickettsial-Like Diseases



Kawasaki Disease





33. Bacterial & Chlamydial Infections

Brian S. Schwartz, MD



Infections Caused by Gram-Positive Bacteria



Infective Endocarditis



Infections Caused by Gram-Negative Bacteria



Actinomycosis



Nocardiosis



Infections Caused by Mycobacteria



Infections Caused by Chlamydiae





34. Spirochetal Infections

Susan S. Philip, MD, MPH



Syphilis



Non-Sexually Transmitted Treponematoses



Selected Spirochetal Diseases



Relapsing Fever



Rat-Bite Fever



Leptospirosis



Lyme Disease (Lyme Borreliosis)





35. Protozoal & Helminthic Infections

Philip J. Rosenthal, MD



Protozoal Infections



African Trypanosomiasis (Sleeping Sickness)



American Trypanosomiasis (Chagas Disease)



Leishmaniasis



Malaria



Babesiosis



Toxoplasmosis



Amebiasis



Infections with Pathogenic Free-Living Amebas



Coccidiosis (Cryptosporidiosis, Isosporiasis, Cyclosporiasis, Sarcocystosis) & Microsporidiosis



Giardiasis



Other Intestinal Flagellate Infections



Trichomoniasis



Helminthic Infections



Trematode (Fluke) Infections



Liver, Lung, & Intestinal Flukes



Cestode Infections



Intestinal Nematode (Roundworm) Infections



Invasive Nematode (Roundworm) Infections



Filariasis





36. Mycotic Infections

Samuel A. Shelburne, MD, & Richard J. Hamill, MD



Candidiasis



Histoplasmosis



Coccidioidomycosis



Pneumocystosis (Pneumocystis jiroveci Pneumonia)



Cryptococcosis



Aspergillosis



Mucormycosis



Blastomycosis



Paracoccidioidomycosis (South American Blastomycosis)



Sporotrichosis



Penicillium marneffei Infections



Chromoblastomycosis (Chromomycosis)



Mycetoma (Maduromycosis & Actinomycetoma)



Other Opportunistic Mold Infections



Antifungal Therapy





37. Disorders Related to Environmental Factors

Jacqueline A. Nemer, MD, FACEP



Cold & Heat



Burns



Electrical Injury



Radiation Exposure



Near Drowning



Other Disorders Related to Environmental Factors





38. Poisoning

Kent R. Olson, MD



Initial Evaluation: Poisoning or Overdose



The Symptomatic Patient



Antidotes & Other Treatment



Diagnosis of Poisoning



Selected Poisonings





39. Cancer

Patricia A. Cornett, MD, & Tiffany O. Dea, PharmD



Etiology



Modifiable Risk Factors



Staging



The Paraneoplastic Syndromes



Types of Cancer



Lung Cancer



Hepatobiliary Cancers



Alimentary Tract Cancers



Cancers of the Genitourinary Tract



Cancer Complications & Emergencies



Primary Cancer Treatment



Systemic Cancer Therapy



Toxicity & Dose Modification of Chemotherapeutic Agents



Prognosis





40. Clinical Genetic Disorders

Reed E. Pyeritz, MD, PhD



Acute Intermittent Porphyria



Alkaptonuria



Down Syndrome



Fragile X Mental Retardation



Gaucher Disease



Disorders of Homocysteine Metabolism



Klinefelter Syndrome



Marfan Syndrome



Hereditary Hemorrhagic Telangiectasia





41. Sports Medicine & Outpatient Orthopedics

Anthony Luke, MD, MPH, & C. Benjamin Ma, MD



General Approach to Musculoskeletal Injuries



Shoulder



Subacromial Impingement Syndrome



Rotator Cuff Tears



Shoulder Dislocation & Instability



Adhesive Capsulitis (“Frozen Shoulder”)



Spine Problems



Low Back Pain



Spinal Stenosis



Lumbar Disk Herniation



Neck Pain



Upper Extremity



Lateral & Medial Epicondylosis



Carpal Tunnel Syndrome



Hip



Hip Fractures



Osteoarthritis



Knee



Knee Pain



Anterior Cruciate Ligament Injury



Collateral Ligament Injury



Posterior Cruciate Ligament Injury



Meniscus Injuries



Patellofemoral Pain



Osteoarthritis



Ankle Injuries



Inversion Ankle Sprains



Eversion (“High”) Ankle Sprains





Appendix: Therapeutic Drug Monitoring, Pharmacogenetic Testing, & Laboratory Reference Intervals

C. Diana Nicoll, MD, PhD, MPA, & Chuanyi Mark Lu, MD, PhD



Index





ONLINE-ONLY CHAPTERS

www.AccessMedicine.com/CMDT





Anti-infective Chemotherapeutic & Antibiotic Agents

B. Joseph Guglielmo, PharmD



Penicillins



Cephalosporins



Other β-Lactam Drugs



Erythromycin Group (Macrolides)



Ketolides



Tetracycline Group



Glycylcyclines



Chloramphenicol



Aminoglycosides



Polymyxins



Antituberculous Drugs



Alternative Drugs in Tuberculosis Treatment



Rifamycins



Sulfonamides & Antifolate Drugs



Sulfones Used in the Treatment of Leprosy



Specialized Drugs Used Against Bacteria



Streptogramins



Oxazolidinediones



Daptomycin



Telavancin



Quinolones



Pentamidine & Atovaquone



Urinary Antiseptics



Antifungal Drugs



Antiviral Chemotherapy





Basic Genetics

Reed E. Pyeritz, MD, PhD



Introduction to Medical Genetics



Genes & Chromosomes



Mutation



Genes in Individuals



Genes in Families



Disorders of Multifactorial Causation



Chromosomal Aberrations



The Techniques of Medical Genetics



Family History & Pedigree Analysis



Cytogenetics & Cytogenomics



Biochemical Genetics



DNA Analysis



Prenatal Diagnosis



Neoplasia: Cytogenomic & DNA Analysis





Diagnostic Testing & Medical Decision Making

C. Diana Nicoll, MD, PhD, MPA, Michael Pignone, MD, MPH, & Chuanyi Mark Lu, MD, PhD



Benefits, Costs, & Risks



Performance of Diagnostic Tests



Test Characteristics



Use of Tests in Diagnosis & Management



Odds-Likelihood Ratios





Information Technology in Patient Care

Russ Cucina, MD, MS



Information Security & Patient Care



Clinical Uses of E-mail



Electronic Health Records



Computerized Provider Order Entry



Clinical Decision Support Systems



Social Media & The World Wide Web



Mobile Computing for Clinicians



Telemedicine





Complementary & Alternative Medicine

Kevin Barrows, MD



Botanical Medicines



Dietary Supplements



Acupuncture



Mind-Body Medicine





Women's Health Issues

Megan McNamara, MD, MSc, & Judith Walsh, MD, MPH



Preventive Health Care



Cardiovascular Disease Prevention



Cancer Prevention



Osteoporosis Prevention



Prevention of Sexually Transmitted Infections



Depression Screening



Specific Issues & Conditions



Intimate Partner Violence



Eating Disorders



Sexuality & Sexual Health



Chronic Pelvic Pain



Mastalgia



The Palpable Breast Mass



Nipple Discharge



Female Pattern Hair Loss



Treatment of Varicose Veins



Age-Related Facial Changes





Authors




Michael J. Aminoff, MD, DSc, FRCP

Professor and Executive Vice Chair, Department of Neurology, University of California, San Francisco; Attending Physician, University of California Medical Center, San Francisco

aminoffm@neurology.ucsf.edu

Nervous System Disorders

David M. Barbour, PharmD, BCPS

Pharmacist, Denver, Colorado

dbarbour99@gmail.com

Drug References

Robert B. Baron, MD, MS

Professor of Medicine; Associate Dean for Graduate and Continuing Medical Education; Vice Chief, Division of General Internal Medicine, University of California, San Francisco

baron@medicine.ucsf.edu

Lipid Disorders; Nutritional Disorders

Kevin Barrows, MD

Associate Clinical Professor of Family and Community Medicine, Medical Director, Osher Center for Integrative Medicine; Department of Family and Community Medicine, University of California, San Francisco

barrowsk@ocim.ucsf.edu

CMDT Online—Complementary & Alternative Medicine

Thomas M. Bashore, MD

Professor of Medicine; Clinical Chief, Division of Cardiology, Duke University Medical Center, Durham, North Carolina

thomas.bashore@duke.edu

Heart Disease

Timothy G. Berger, MD

Professor of Clinical Dermatology, Department of Dermatology, University of California, San Francisco

bergert@derm.ucsf.edu

Dermatologic Disorders

Ranjan Chanda, MD, MPH

Transplant Nephrology Fellow, Division of Nephrology, Department of Medicine, University of California, San Francisco

References

Bonnie Chen, MD

Chief Medical Resident, Ambulatory Care, Department of Medicine, University of California, San Francisco

References

Hugo Q. Cheng, MD

Clinical Professor of Medicine, Division of Hospital Medicine, University of California, San Francisco; Director, Medical Consultation Service, University of California Medical Center, San Francisco

quinny@medicine.ucsf.edu

Preoperative Evaluation & Perioperative Management

Mark S. Chesnutt, MD

Clinical Professor, Pulmonary & Critical Care Medicine, Dotter Interventional Institute, Oregon Health & Science University, Portland, Oregon; Director, Critical Care, Portland Veterans Affairs Medical Center

chesnutm@ohsu.edu

Pulmonary Disorders

Peter V. Chin-Hong, MD

Associate Professor, Division of Infectious Diseases, Department of Medicine, University of California, San Francisco

phong@php.ucsf.edu

Common Problems in Infectious Diseases & Antimicrobial Therapy

Kerry C. Cho, MD

Assistant Clinical Professor of Medicine, Division of Nephrology, University of California, San Francisco

kerry.cho@ucsf.edu

Electrolyte & Acid-Base Disorders

Leslie R. Cockerham, MD

Chief Medical Resident, Moffitt-Long Hospital, Department of Medicine, University of California, San Francisco

References

Denise M. Connor, MD

Chief Medical Resident, San Francisco Veterans Affairs Medical Center, Department of Medicine, University of California, San Francisco

References

Patricia A. Cornett, MD

Professor of Medicine, University of California, San Francisco; Chief, Hematology/Oncology, San Francisco Veterans Affairs Medical Center, San Francisco, California

patricia.cornett@va.gov

Cancer

Russ Cucina, MD, MS

Assistant Professor of Medicine, Division of Hospital Medicine; Associate Medical Director, Information Technology, UCSF Medical Center; University of California, San Francisco

rcucina@medicine.ucsf.edu

CMDT Online—Information Technology in Patient Care

Lloyd E. Damon, MD

Clinical Professor of Medicine, Department of Medicine, Division of Hematology/Oncology; Director of Adult Hematologic Malignancies and Blood and Marrow Transplantation, University of California, San Francisco

damonl@medicine.ucsf.edu

Blood Disorders

Tiffany O. Dea, PharmD

Oncology Pharmacist, Veterans Affairs Medical Center, San Francisco, California; Adjunct Professor, Thomas J. Long School of Pharmacy and Health Sciences, Stockton, California

tiffany.dea@va.gov

Cancer

Tonja Dirkx, MD

Assistant Professor of Medicine, Division of Nephrology, Department of Medicine, Oregon Health and Sciences University, Portland, Oregon; Renal Clinic Director, Portland Veterans Affairs Medical Center

dirkxt@ohsu.edu

Kidney Disease

Stuart J. Eisendrath, MD

Professor of Psychiatry; Director of Clinical Services and The UCSF Depression Center, Langley Porter Psychiatric Hospital and Clinics, University of California, San Francisco

stuart.eisendrath@ucsf.edu

Psychiatric Disorders

Paul A. Fitzgerald, MD

Clinical Professor of Medicine, Department of Medicine, Division of Endocrinology, University of California, San Francisco

paul.fitzgerald@ucsf.edu

Endocrine Disorders

Patrick F. Fogarty, MD

Assistant Professor of Medicine, Department of Medicine; Director, Penn Comprehensive Hemophilia and Thrombosis Program, Hospital of the University of Pennsylvania, Philadelphia,

patrick.fogarty@uphs.upenn.edu

Disorders of Hemostasis, Thrombosis, & Antithrombotic Therapy

Lawrence S. Friedman, MD

Professor of Medicine, Harvard Medical School; Professor of Medicine, Tufts University School of Medicine, Boston, Massachusetts; Chair, Department of Medicine, Newton-Wellesley Hospital, Newton, Massachusetts; Assistant Chief of Medicine, Massachusetts General Hospital, Boston, Massachusetts

lfriedman@partners.org

Liver, Biliary Tract, & Pancreas Disorders; Hepatobiliary Cancers (in Chapter 39)

Armando E. Giuliano, MD

Chief of Science and Medicine, John Wayne Cancer Institute; Director, John Wayne Cancer Institute Breast Center, Saint John's Health Center, Santa Monica, California

giulianoa@jwci.org

Breast Disorders

Ralph Gonzales, MD, MSPH

Professor of Medicine; Professor of Epidemiology & Biostatistics, Division of General Internal Medicine, Department of Medicine, University of California, San Francisco

ralphg@medicine.ucsf.edu

Common Symptoms

Christopher B. Granger, MD

Professor of Medicine; Director, Cardiac Care Unit, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina

grang001@mc.duke.edu

Heart Disease

B. Joseph Guglielmo, PharmD

Professor and Chair, Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco

guglielmoj@pharmacy.ucsf.edu

Common Problems in Infectious Diseases & Antimicrobial Therapy; CMDT Online—Anti-infective Chemotherapeutic & Antibiotic Agents

Richard J. Hamill, MD

Professor, Division of Infectious Diseases, Departments of Medicine and Molecular Virology & Microbiology, Baylor College of Medicine, Houston, Texas

richard.hamill@med.va.gov

Mycotic Infections

G. Michael Harper, MD

Associate Professor, Department of Medicine, University of California San Francisco School of Medicine; Associate Chief of Staff for Geriatrics, Palliative and Extended Care, San Francisco Veterans Affairs Medical Center, San Francisco, California

michael.harper3@med.va.gov

Geriatric Disorders

David B. Hellmann, MD, MACP

Aliki Perroti Professor of Medicine; Vice Dean for Johns Hopkins Bayview; Chairman, Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland

hellmann@jhmi.edu

Musculoskeletal & Immunologic Disorders

Patrick Hranitzky, MD

Assistant Professor of Medicine; Director, Clinical Cardiac Electrophysiology; Director, Clinical Cardiac Electrophysiology Fellowship Program, Duke University Medical Center, Durham, North Carolina

patrick.hranitzky@duke.edu

Heart Disease

Sara A. Hurvitz, MD

Assistant Professor; Director, Breast Oncology Program, Division of Hematology/Oncology, Department of Internal Medicine, University of California, Los Angeles

shurvitz@mednet.ucla.edu

Breast Disorders

John B. Imboden, Jr., MD

Alice Betts Endowed Chair for Arthritis Research; Professor of Medicine, University of California, San Francisco; Chief, Division of Rheumatology, San Francisco General Hospital

jimboden@medsfgh.ucsf.edu

Musculoskeletal & Immunologic Disorders

Meshell D. Johnson, MD

Assistant Professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco

meshell.johnson@ucsf.edu

Blood Vessel & Lymphatic Disorders

C. Bree Johnston, MD, MPH

Professor of Medicine, Division of Geriatrics, Department of Medicine, Veterans Affairs Medical Center, University of California, San Francisco

bree.johnston@ucsf.edu

Geriatric Disorders

Mitchell H. Katz, MD

Clinical Professor of Medicine, Epidemiology & Biostatistics, University of California, San Francisco; Director of Health, San Francisco Department of Public Health

mitch.katz@sfdph.org

HIV Infection & AIDS

Robin K. Kelley, MD

Assistant Professor of Medicine, Division of Hematology/Oncology, University of California, San Francisco; Staff Physician, San Francisco Veterans Affairs Medical Center

katie.kelley@ucsf.edu

Alimentary Tract Cancers (in Chapter 39)

Geoffrey A. Kerchner, MD, PhD

Assistant Professor of Neurology and Neurological Sciences, Stanford Center for Memory Disorders, Stanford University School of Medicine, Stanford, California

kerchner@stanford.edu

Nervous System Disorders

Gregory M. Ku, MD, PhD

Clinical Instructor, Division of Endocrinology and Metabolism, University of California, San Francisco

References

C. Seth Landefeld, MD

Professor; Chief, Division of Geriatrics; Director, UCSF-Mt. Zion Center on Aging, University of California, San Francisco; Director, Quality Scholars Fellowship Program, San Francisco Veterans Affairs Medical Center

sethl@medicine.ucsf.edu

Geriatric Disorders

Christina A. Lee, MD

Chief Resident, Moffitt-Long Hospital, Department of Medicine, University of California, San Francisco

References

Jonathan E. Lichtmacher, MD

Health Sciences Clinical Professor of Psychiatry; Director, Adult Psychiatry Clinic, Langley Porter Hospitals and Clinics, University of California, San Francisco

jonathanl@lppi.ucsf.edu

Psychiatric Disorders

Charles A. Linker, MD

Professor of Medicine Emeritus, University of California, San Francisco

linkerc@medicine.ucsf.edu

Blood Disorders

Chuanyi Mark Lu, MD, PhD

Associate Professor, Department of Laboratory Medicine, University of California, San Francisco; Chief, Hematology and Hematopathology, Laboratory Medicine Service, Veterans Affairs Medical Center, San Francisco, California

mark.lu@va.gov

Appendix: Therapeutic Drug Monitoring, Pharmacogenetic Testing, & Laboratory Reference Intervals; CMDT Online—Diagnostic Testing & Medical Decision Making

Anthony Luke, MD, MPH

Associate Professor, Department of Orthopaedics; Director, UCSF Primary Care Sports Medicine; Director, Human Performance Center at the Orthopaedic Institute, University of California, San Francisco

LukeA@orthosurg.ucsf.edu

Sports Medicine & Outpatient Orthopedics

Lawrence R. Lustig, MD

Francis A. Sooy, MD Professor of Otolaryngology—Head & Neck Surgery; Division Chief of Otology & Neurotology, Department of Otolaryngology—Head & Neck Surgery, University of California, San Francisco

llustig@ohns.ucsf.edu

Ear, Nose, & Throat Disorders

C. Benjamin Ma, MD

Associate Professor, Department of Orthopaedic Surgery;

Chief, Sports Medicine and Shoulder Service, University of California, San Francisco

MaBen@orthosurg.ucsf.edu

Sports Medicine & Outpatient Orthopedics

H. Trent MacKay, MD, MPH

Professor of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Staff Physician, Department of Obstetrics and Gynecology, National Naval Medical Center, Bethesda, Maryland

mackayt@mail.nih.gov

Gynecologic Disorders

Umesh Masharani, MB, BS, MRCP (UK)

Professor of Medicine, Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco

umesh.masharani@ucsf.edu

Diabetes Mellitus & Hypoglycemia

Megan McNamara, MD, MSc

Assistant Professor of Medicine, Department of Medicine, Case Western Reserve University, Cleveland, Ohio; Women's Health Medical Director, Louis Stokes Cleveland Veterans Affairs Medical Center

Megan.Mcnamara@va.gov

CMDT Online—Women's Health Issues

Kenneth R. McQuaid, MD

Professor of Clinical Medicine, University of California, San Francisco; Chief, Gastroenterology Section, San Francisco Veterans Affairs Medical Center

kenneth.mcquaid@med.va.gov

Gastrointestinal Disorders; Alimentary Tract Cancers (in Chapter 39)

Maxwell V. Meng, MD, FACS

Associate Professor, Department of Urology, University of California, San Francisco

mmeng@urology.ucsf.edu

Urologic Disorders; Cancers of the Genitourinary Tract (in Chapter 39)

Tracy Minichiello, MD

Associate Professor of Medicine, University of California, San Francisco; Chief, Anticoagulation and Thrombosis Services, San Francisco Veterans Affairs Medical Center

minichie@medicine.ucsf.edu

Disorders of Hemostasis, Thrombosis, & Antithrombotic Therapy

Paul L. Nadler, MD

Associate Clinical Professor of Medicine; Director, Screening and Acute Care Clinic, Division of General Internal Medicine, Department of Medicine, University of California, San Francisco

nadler@medicine.ucsf.edu

Common Symptoms

Jacqueline A. Nemer, MD, FACEP

Associate Professor of Emergency Medicine, Department of Emergency Medicine, University of California, San Francisco

jacqueline.nemer@ucsf.edu

Disorders Related to Environmental Factors

C. Diana Nicoll, MD, PhD, MPA

Clinical Professor and Vice Chair, Department of Laboratory Medicine; Associate Dean, University of California, San Francisco; Chief of Staff and Chief, Laboratory Medicine Service, San Francisco Veterans Affairs Medical Center

diana.nicoll@va.gov

Appendix: Therapeutic Drug Monitoring, Pharmacogenetic Testing, & Laboratory Reference Intervals; CMDT Online—Diagnostic Testing & Medical Decision Making

Grace J. No, MD

Fellow, Division of Nephrology, Department of Medicine, University of California, San Francisco

References

Kent R. Olson, MD

Clinical Professor of Medicine, Pediatrics, and Pharmacy, University of California, San Francisco; Medical Director, San Francisco Division, California Poison Control System

kent.olson@ucsf.edu

Poisoning

Robert Osterhoff, MD

Fellow, Division of Gastroenterology, Department of Medicine, University of California, San Francisco

References

Christopher D. Owens, MD, MSc

Assistant Professor of Surgery, Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco

christopher.owens@ucsfmedctr.org

Blood Vessel & Lymphatic Disorders

Steven Z. Pantilat, MD

Professor of Clinical Medicine, Department of Medicine; Alan M. Kates and John M. Burnard Endowed Chair in Palliative Care; Director, Palliative Care Program, University of California, San Francisco

stevep@medicine.ucsf.edu

Palliative Care & Pain Management

Manesh R. Patel, MD

Assistant Professor of Medicine, Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina

patel017@notes.duke.edu

Heart Disease

Shruti Patel, MD

Fellow, Division of Infectious Diseases, Department of Internal Medicine, Baylor College of Medicine, Houston, Texas

shrutip@bcm.tmc.edu

Viral & Rickettsial Infections

Susan S. Philip, MD, MPH

Assistant Clinical Professor, Division of Infectious Diseases, Department of Medicine, University of California, San Francisco; Director, STD Prevention and Control Section, San Francisco Department of Public Health, San Francisco, California

susan.philip@sfdph.org

Spirochetal Infections

Michael Pignone, MD, MPH

Professor of Medicine, Division of General Internal Medicine, Department of Medicine, University of North Carolina, Chapel Hill

pignone@med.unc.edu

Disease Prevention & Health Promotion; CMDT Online—Diagnostic Testing & Medical Decision Making

Thomas J. Prendergast, MD

Associate Professor of Medicine, Oregon Health and Science University; Section Chief, Portland Veterans Affairs Medical Center, Portland, Oregon

thomas.prendergast@va.gov

Pulmonary Disorders

Reed E. Pyeritz, MD, PhD

Professor of Medicine and Genetics; Vice-Chair for Academic Affairs, Department of Medicine, Raymond and Ruth Perelman School of Medicine of the University of Pennsylvania, Philadelphia

reed.pyeritz@uphs.upenn.edu

Clinical Genetic Disorders; CMDT Online—Basic Genetics

Gene R. Quinn, MD, MS

Resident Physician, Department of Medicine, University of California, San Francisco

References

Michael W. Rabow, MD, FAAHPM

Professor of Medicine, Division of General Internal Medicine, Department of Medicine; Director, Symptom Management Service, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco

mrabow@medicine.ucsf.edu

Palliative Care & Pain Management

Joseph H. Rapp, MD

Professor of Surgery in Residence, University of California,

San Francisco; Chief, Vascular Surgery Service, Veterans Affairs Medical Center, San Francisco, California

rappj@surgery.ucsf.edu

Blood Vessel & Lymphatic Disorders

Paul Riordan-Eva, FRCS, FRCOphth

Consultant Ophthalmologist, King's College Hospital;

Honorary Senior Lecturer (Teaching), King's College London School of Medicine at Guy's, King's College, and St. Thomas’ Hospitals, London, United Kingdom

paulreva@doctors.org.uk

Disorders of the Eyes & Lids

Vanessa L. Rogers, MD

Assistant Professor, Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas

vanessa.rogers@utsouthwestern.edu

Obstetrics & Obstetric Disorders

Philip J. Rosenthal, MD

Professor, Division of Infectious Diseases, Department of Medicine, University of California, San Francisco; San Francisco General Hospital

prosenthal@medsfgh.ucsf.edu

Protozoal & Helminthic Infections

René Salazar, MD

Assistant Clinical Professor, Division of General Internal Medicine, Department of Medicine, University of California, San Francisco

salazarr@medicine.ucsf.edu

Disease Prevention & Health Promotion

Joshua S. Schindler, MD

Assistant Professor, Department of Otolaryngology, Oregon Health & Science University, Portland, Oregon; Medical Director, OHSU-Northwest Clinic for Voice and Swallowing

schindlj@ohsu.edu

Ear, Nose, & Throat Disorders

Brian S. Schwartz, MD

Assistant Clinical Professor, Division of Infectious Diseases, Department of Medicine, University of California, San Francisco

brian.schwartz@ucsf.edu

Bacterial & Chlamydial Infections

Wayne X. Shandera, MD

Assistant Professor, Department of Internal Medicine, Baylor College of Medicine, Houston, Texas

shandera@bcm.tmc.edu

Viral & Rickettsial Infections

Samuel A. Shelburne, MD

Assistant Professor, Department of Internal Medicine, Baylor College of Medicine, Houston, Texas

samuels@bcm.tmc.edu

Mycotic Infections

Jenny Siegel, MD

Chief Resident, San Francisco General Hospital, Department of Medicine, University of California, San Francisco

References

Marshall L. Stoller, MD

Professor and Vice Chairman, Department of Urology, University of California, San Francisco

mstoller@urology.ucsf.edu

Urologic Disorders

Michael Sutters, MD, MRCP(UK)

Attending Nephrologist, Virginia Mason Medical Center, Seattle, Washington; Affiliate Assistant Professor of Medicine, Division of Nephrology, University of Washington School of Medicine, Seattle, Washington

michael.sutters@vmmc.org

Systemic Hypertension

Adam Templeton, MD

Chief Medical Resident, San Francisco Veterans Affairs Medical Center, Department of Medicine, University of California, San Francisco

References

Philip Tiso

Principal Editor, Division of General Internal Medicine, University of California, San Francisco

References

Judith Walsh, MD, MPH

Professor of Clinical Medicine, Division of General Internal Medicine, Women's Health Center of Excellence, University of California, San Francisco

Judith.Walsh@ucsf.edu

CMDT Online—Women's Health Issues

Thomas J. Walsh, MD, MS

Assistant Professor, Department of Urology, University of Washington School of Medicine, Seattle, Washington

walsht@u.washington.edu

Urologic Disorders

Sunny Wang, MD

Assistant Clinical Professor of Medicine, Division of Hematology and Oncology, University of California, San Francisco; San Francisco Veterans Affairs Medical Center

sunny.wang@ucsf.edu

Lung Cancer (in Chapter 39)

Suzanne Watnick, MD

Associate Professor of Medicine, Division of Nephrology and Hypertension, Oregon Health & Science University, Portland; Director, Dialysis Unit, Portland Veterans Affairs Medical Center, Portland, Oregon

watnicks@ohsu.edu

Kidney Disease

Kevin C. Worley, MD

Assistant Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas

Kevin.Worley@UTSouthwestern.edu

Obstetrics & Obstetric Disorders

Andrew R. Zolopa, MD

Associate Professor of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California

azolopa@stanford.edu

HIV Infection & AIDS





Preface




Current Medical Diagnosis & Treatment 2012 is the 51st edition of this single-source reference for practitioners in both hospital and ambulatory settings. The book emphasizes the practical features of clinical diagnosis and patient management in all fields of internal medicine and in specialties of interest to primary care practitioners and to subspecialists who provide general care.





INTENDED AUDIENCE


House officers, medical students, and all other health professions students will find the descriptions of diagnostic and therapeutic modalities, with citations to the current literature, of everyday usefulness in patient care.

Internists, family physicians, hospitalists, nurse practitioners, physicians’ assistants, and all primary care providers will appreciate CMDT as a ready reference and refresher text. Physicians in other specialties, pharmacists, and dentists will find the book a useful basic medical reference text. Nurses, nurse-practitioners, and physicians’ assistants will welcome the format and scope of the book as a means of referencing medical diagnosis and treatment.

Patients and their family members who seek information about the nature of specific diseases and their diagnosis and treatment may also find this book to be a valuable resource.





NEW IN THIS EDITION


• New data outlining criteria for axillary node dissection in breast cancer

• New topics: Snoring; and a selection of common musculoskeletal problems including subacromial impingement syndrome, rotator cuff tear, anterior cruciate ligament and meniscus injuries, patellofemoral pain syndrome, and inversion and eversion ankle sprains

• Revised discussion on radiation exposure from medical procedures

• Recommendations for dabigatran anticoagulation therapy

• Extensive revision of Kidney Disease chapter

• Substantial revision on medical and surgical complications during pregnancy

• Significant update on the safety of thiazolidinediones and the role of bariatric surgery in patients with diabetes mellitus

• Updated section on evaluating infertility in women

• Update on antiemetics and use and safety of nonsteroidal anti-inflammatory drugs

• Updated section on immunization requirements

• Inclusion of Sports Medicine & Outpatient Orthopedics chapter

• New CMDT Online chapter on Women's Health Issues





OUTSTANDING FEATURES


• Medical advances up to time of annual publication

• Detailed presentation of all primary care topics, including gynecology, obstetrics, dermatology, ophthalmology, otolaryngology, psychiatry, neurology, toxicology, urology, geriatrics, orthopedics, preventive medicine, and palliative care

• Concise format, facilitating efficient use in any practice setting

• More than 1000 diseases and disorders

• Only text with annual update on HIV infection and AIDS

• Specific disease prevention information

• Easy access to drug dosages, with trade names indexed and costs updated in each edition

• Recent references, with unique identifiers (PubMed, PMID numbers) for rapid downloading of article abstracts and, in some instances, full-text reference articles

• ICD-9 codes listed on the inside covers



CMDT Online (www.AccessMedicine.com) provides full electronic access to CMDT 2012 plus expanded basic science information and six additional chapters. The six online-only chapters (Anti-infective Chemotherapeutic & Antibiotic Agents, Basic Genetics, Diagnostic Testing & Medical Decision Making, Information Technology in Patient Care, Complementary & Alternative Medicine, and Women's Health Issues) are available at www.AccessMedicine.com/CMDT.

CMDT Online is updated throughout the year and includes a dedicated Media Gallery as well as links to related Web sites. Subscribers also receive access to Diagnosaurus with 1000+ differential diagnoses, Pocket Guide to Diagnostic Tests, Quick Answers, and CURRENT Practice Guidelines in Primary Care.





ACKNOWLEDGMENTS


We wish to thank our associate authors for participating once again in the annual updating of this important book. We are especially grateful to two authors who are leaving CMDT this year: Susan Cox, MD and Gail Morrison, MD. These authors have contributed hours upon hours of work in culling and distilling the literature in their specialty areas and we have all benefited from their clinical wisdom and commitment.

Many students and physicians also have contributed useful suggestions to this and previous editions, and we are grateful. We continue to welcome comments and recommendations for future editions in writing or via electronic mail. The editors’ and authors’ institutional and e-mail addresses are given in the Authors section.

Stephen J. McPhee, MD

smcphee@medicine.ucsf.edu

Maxine A. Papadakis, MD

papadakM@medsch.ucsf.edu

Michael W. Rabow, MD

mrabow@medicine.ucsf.edu

San Francisco, California

September 2011





From inability to let alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, and science before art and cleverness before common sense; from treating patients as cases; and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.

—Sir Robert Hutchison





Disease Prevention &

Health Promotion



Michael Pignone, MD, MPH,

& René Salazar, MD





GENERAL APPROACH TO THE PATIENT




The medical interview serves several functions. It is used to collect information to assist in diagnosis (the “history” of the present illness), to assess and communicate prognosis, to establish a therapeutic relationship, and to reach agreement with the patient about further diagnostic procedures and therapeutic options. It also serves as an opportunity to influence patient behavior, such as in motivational discussions about smoking cessation or medication adherence. Interviewing techniques that avoid domination by the clinician increase patient involvement in care and patient satisfaction. Effective clinician-patient communication and increased patient involvement can improve health outcomes.

Patient Adherence

For many illnesses, treatment depends on difficult fundamental behavioral changes, including alterations in diet, taking up exercise, giving up smoking, cutting down drinking, and adhering to medication regimens that are often complex. Adherence is a problem in every practice; up to 50% of patients fail to achieve full adherence, and one-third never take their medicines. Many patients with medical problems, even those with access to care, do not seek appropriate care or may drop out of care prematurely. Adherence rates for short-term, self-administered therapies are higher than for long-term therapies and are inversely correlated with the number of interventions, their complexity and cost, and the patient's perception of overmedication.

As an example, in HIV-infected patients, adherence to antiretroviral therapy is a crucial determinant of treatment success. Studies have unequivocally demonstrated a close relationship between patient adherence and plasma HIV RNA levels, CD4 cell counts, and mortality. Adherence levels of > 95% are needed to maintain virologic suppression. However, studies show that over 60% of patients are < 90% adherent and that adherence tends to decrease over time.

Patient reasons for nonadherence include simple forgetfulness, being away from home, being busy, and changes in daily routine. Other reasons include psychiatric disorders (depression or substance abuse), uncertainty about the effectiveness of treatment, lack of knowledge about the consequences of poor adherence, regimen complexity, and treatment side effects.

Patients seem better able to take prescribed medications than to adhere to recommendations to change their diet, exercise habits, or alcohol intake or to perform various self-care activities (such as monitoring blood glucose levels at home). A 2008 review on the effectiveness of interventions to improve medication adherence found that for short-term regimens, adherence to medications can be improved by giving clear instructions. Writing out advice to patients, including changes in medication, may be helpful. Because low functional health literacy is common (almost half of English-speaking US patients are unable to read and understand standard health education materials), other forms of communication—such as illustrated simple text, videotapes, or oral instructions—may be more effective. For non–English-speaking patients, clinicians and health care delivery systems can work to provide culturally and linguistically appropriate health services.

To help improve adherence to long-term regimens, clinicians can work with patients to reach agreement on the goals for therapy, provide information about the regimen, ensure understanding by using the “teach-back” method, counsel about the importance of adherence and how to organize medication-taking, reinforce self-monitoring, provide more convenient care, prescribe a simple dosage regimen for all medications (preferably one or two doses daily), suggest ways to help in remembering to take doses (time of day, mealtime, alarms) and to keep appointments, and provide ways to simplify dosing (medication boxes). Single-unit doses supplied in foil wrappers can increase adherence but should be avoided for patients who have difficulty opening them. Medication boxes with compartments (eg, Medisets) that are filled weekly are useful. Microelectronic devices can provide feedback to show patients whether they have taken doses as scheduled or to notify patients within a day if doses are skipped. Reminders, including cell phone text messages, are another effective means of encouraging adherence. The clinician can also enlist social support from family and friends, recruit an adherence monitor, provide a more convenient care environment, and provide rewards and recognition for the patient's efforts to follow the regimen. Collaborative programs that utilize pharmacists to help ensure adherence have also been shown to be effective.

Adherence is also improved when a trusting doctor-patient relationship has been established and when patients actively participate in their care. Clinicians can improve patient adherence by inquiring specifically about the behaviors in question. When asked, many patients admit to incomplete adherence with medication regimens, with advice about giving up cigarettes, or with engaging only in “safer sex” practices. Although difficult, sufficient time must be made available for communication of health messages.

Medication adherence can be assessed generally with a single question: “In the past month, how often did you take your medications as the doctor prescribed?” Other ways of assessing medication adherence include pill counts and refill records; monitoring serum, urine, or saliva levels of drugs or metabolites; watching for appointment nonattendance and treatment nonresponse; and assessing predictable drug effects such as weight changes with diuretics or bradycardia from β-blockers. In some conditions, even partial adherence, as with drug treatment of hypertension and diabetes mellitus, improves outcomes compared with nonadherence; in other cases, such as HIV antiretroviral therapy or treatment of tuberculosis, partial adherence may be worse than complete nonadherence.





Guiding Principles of Care


Ethical decisions are often called for in medical practice, at both the “micro” level of the individual patient-clinician relationship and at the “macro” level of the allocation of resources. Ethical principles that guide the successful approach to diagnosis and treatment are honesty, beneficence, justice, avoidance of conflict of interest, and the pledge to do no harm. Increasingly, Western medicine involves patients in important decisions about medical care, including how far to proceed with treatment of patients who have terminal illnesses (see Chapter 5).

The clinician's role does not end with diagnosis and treatment. The importance of the empathic clinician in helping patients and their families bear the burden of serious illness and death cannot be overemphasized. “To cure sometimes, to relieve often, and to comfort always” is a French saying as apt today as it was five centuries ago—as is Francis Peabody's admonition: “The secret of the care of the patient is in caring for the patient.” Training to improve mindfulness and enhance patient-centered communication increases patient satisfaction and may also improve clinician satisfaction.

Haynes RB et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD000011. [PMID: 18425859]



Krasner MS et al. Association of an educational program in mindful communication with burnout, empathy and attitudes among primary care physicians. JAMA. 2009 Sep 23; 302(12):1284–93. [PMID: 19773563]



Lester RT et al. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet. 2010 Nov 27;376(9755): 1838–45. [PMID: 21071074]



Weber CA et al. Pharmacist-physician co-management of hypertension and reduction in 24-hour ambulatory blood pressures. Arch Intern Med. 2010 Oct 11;170(18):1634–9. [PMID: 20937921]





HEALTH MAINTENANCE & DISEASE PREVENTION




Preventive medicine can be categorized as primary, secondary, or tertiary. Primary prevention aims to remove or reduce disease risk factors (eg, immunization, giving up or not starting smoking). Secondary prevention techniques promote early detection of disease or precursor states (eg, routine cervical Papanicolaou screening to detect carcinoma or dysplasia of the cervix). Tertiary prevention measures are aimed at limiting the impact of established disease (eg, partial mastectomy and radiation therapy to remove and control localized breast cancer). Tables 1–1 and 1–2 give leading causes of death in the United States and estimates of deaths from preventable causes.

Many effective preventive services are underutilized, and few adults receive all of the most strongly recommended services. The three highest-ranking services in terms of potential health benefits and cost-effectiveness include discussing aspirin use with high-risk adults, tobacco-use screening and brief interventions, and immunizing children. Other high-ranking services with data with substantial room for improvement in utilization are screening adults aged 50 and older for colorectal cancer, immunizing adults aged 65 and older against pneumococcal disease, and screening young women for Chlamydia.

Several methods, including the use of provider or patient reminder systems, reorganization of care environments, and possibly provision of financial incentives, can increase utilization of preventive services, but such methods have not been widely adopted.



Table 1–1. Leading causes of death in the United States, 2008.





Category

Estimate

All causes 2,472,699

1. Diseases of the heart 617,527

2. Malignant neoplasms 566,137

3. Chronic lower respiratory diseases 141,075

4. Cerebrovascular diseases 133,750

5. Accidents (unintentional injuries) 121,207

6. Alzheimer disease 82,476

7. Diabetes mellitus 70,601

8. Influenza and pneumonia 56,335

9. Nephritis, nephrotic syndrome, and nephrosis 48,283

10. Septicemia 35,961



Source: National Center for Health Statistics 2010.



Table 1–2. Deaths from all causses attributable to common preventable risk factors. (Numbers given in the thousands.)





BMI, body mass index; CI, confidence interval; LDL, low-density lipoprotein.

Note: Numbers of deaths cannot be summed across categories.

Used, with permission, from Danaei G et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med. 2009 Apr 28;6(4):e1000058.

Danaei G et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med. 2009 Apr 28;6(4):e1000058. [PMID: 19399161]



Gavagan TF et al. Effect of financial incentives on improvement in medical quality indicators for primary care. J Am Board Fam Med. 2010 Sep–Oct;23(5):622–31. [PMID: 20823357]



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PREVENTION OF INFECTIOUS DISEASES


Much of the decline in the incidence and fatality rates of infectious diseases is attributable to public health measures—especially immunization, improved sanitation, and better nutrition.

Immunization remains the best means of preventing many infectious diseases. Recommended immunization schedules for children and adolescents can be found online at www.cdc.gov/vaccines/rec/schedules, and the schedule for adults is outlined in Table 30–12. Thimerosal-free hepatitis B vaccination is available for newborns and infants, and despite the disproved relationship between vaccines and autism, thimerosal-free vaccines are available for pregnant women. Substantial vaccine-preventable morbidity and mortality continue to occur among adults from vaccine-preventable diseases, such as hepatitis A, hepatitis B, influenza, and pneumococcal infections. For example, in adults in the United States, there are an estimated 50,000–70,000 deaths annually from influenza, hepatitis B, and invasive pneumococcal disease. Strategies to enhance vaccinations include increasing community demand for vaccinations; enhancing access to vaccination services; and provider- or system-based interventions, such as reminder systems.

Evidence suggests annual influenza vaccination is safe and effective with potential benefit in all age groups, and the Advisory Committee on Immunization Practices (ACIP) recommends routine influenza vaccination for all persons aged 6 months and older, which is an expansion of previous recommendations for annual vaccination of all adults aged 19–49 years. When vaccine supply is limited, certain groups should be given priority, such as adults 50 years and older, individuals with chronic illness or immunosuppression, and pregnant women. An alternative high-dose inactivated vaccine for adults 65 years and older is available. This inactivated trivalent vaccine contains 60 mcg of hemagglutinin antigen per influenza vaccine virus strain (Fluzone High-Dose [Sanofi Pasteur]). Adults 65 years and older can receive either the standard dose or high-dose vaccine, whereas those younger than 65 years should receive a standard-dose preparation.

Increasing reports of pertussis among US adolescents, adults, and their infant contacts have stimulated vaccine development for older age groups. In 2010, several states reported an increase in the number of pertussis cases, including California where more than 7000 cases were reported. A safe and effective tetanus-diphtheria 5-component acellular pertussis vaccine (Tdap) is available for use in adolescents and in adults younger than 65 years. Compared with DTaP, which is used in children under the age of 7, Tdap has a reduced dose of the diphtheria and pertussis vaccines. The ACIP recommends routine use of a single dose of Tdap for adults aged 19–64 years to replace the next booster dose of tetanus and diphtheria toxoids vaccine (Td). Due to increasing reports of pertussis in the United States, clinicians may choose to give Tdap to persons aged 65 years and older despite limited published data on the safety and efficacy of the vaccine in this age group.

Both hepatitis A vaccine and immune globulin provide protection against hepatitis A; however, administration of immune globulin may provide a modest benefit over vaccination in some settings. A recombinant protein hepatitis E vaccine has been developed that has proven safe and efficacious in preventing hepatitis E among high-risk populations (such as those in Nepal).

Human papillomavirus (HPV) virus-like particle (VLP) vaccines have demonstrated effectiveness in preventing persistent HPV infections, and thus may impact the rate of cervical intraepithelial neoplasia (CIN) II–III. The American Cancer Society and the American Academy of Pediatrics (AAP) recommends routine HPV vaccination for girls aged 11–12 years. The AAP also recommends that all unvaccinated girls and women ages 13–26 years receive the HPV vaccine. Trials demonstrate efficacy of bivalent HPV (16/18) or quadrivalent HPV (6/11/16/18) L1 virus-like particle vaccines in preventing new HPV infection and cervical lesions but not in women with preexisting infection. It is estimated that routine use of HPV vaccination of females at 11 to 12 years of age and catch-up vaccination of females at age 13–16 (with vaccination of girls age 9 and 10 at the discretion of the physician) could prevent 95% to 100% of CIN and adenocarcinoma in situ, 99% of genital warts and approximately 70% of cervical cancer cases worldwide; thus, the role of HPV testing will need redefinition. Despite the effectiveness of the vaccine, rates of immunization are low. Interventions addressing personal beliefs and system barriers to vaccinations may help address the slow adoption of this vaccine.

Persons traveling to countries where infections are endemic should take precautions described in Chapter 30. Immunization registries—confidential, population-based, computerized information systems that collect vaccination data about all residents of a geographic area—can be used to increase and sustain high vaccination coverage.

Skin testing for tuberculosis and treating selected patients reduce the risk of reactivation tuberculosis (see Table 9–11). Two blood tests, which are not confounded by prior BCG (bacille Calmette-Guérin) vaccination, have been developed to detect tuberculosis infection by measuring in vitro T-cell interferon-gamma release in response to two antigens (the enzyme-linked immunospot [ELISpot], [T-SPOT.TB] and the other, a quantitative ELISA [QuantiFERON-TBGold] test). These T-cell–based assays have an excellent specificity that is higher than tuberculin skin testing in BCG-vaccinated populations. The rate of tuberculosis in the United States has been declining since 1992. In 2009, the US tuberculosis rate was 3.8 cases per 100,000 population, a decrease of 11.4% from the 2008 rate (4.2 per 100,000). This represents the greatest single-year decrease ever recorded and was the lowest recorded rate since national tuberculosis surveillance began in 1953.

The Advisory Council for the Elimination of Tuberculosis has called for a renewed commitment to eliminating tuberculosis in the United States, and the Institute of Medicine has published a detailed plan for achieving that goal. Patients with HIV infection are at an especially high risk for tuberculosis, and tuberculosis preventive therapy in the era of HIV will require further work to overcome implementation barriers and to identify optimal duration of preventive therapy and treatment approach for individuals receiving highly active antiretroviral therapy (HAART).

Treatment of tuberculosis poses a risk of hepatotoxicity and thus requires close monitoring of liver transaminases. Alanine aminotransferase (ALT) monitoring during the treatment of latent tuberculosis infection is recommended for certain individuals (preexisting liver disease, pregnancy, chronic alcohol consumption). ALT should be monitored in HIV-infected patients during treatment of tuberculosis disease and should be considered in patients over the age of 35. Symptomatic patients with an ALT elevation three times the upper limit of normal (ULN) or asymptomatic patients with an elevation five times the ULN should be treated with a modified or alternative regimen.

HIV infection is now the major infectious disease problem in the world, and it affects 850,000–950,000 persons in the United States. Since sexual contact is a common mode of transmission, primary prevention relies on eliminating unsafe sexual behavior by promoting abstinence, later onset of first sexual activity, decreased number of partners, and use of latex condoms. Appropriately used, condoms can reduce the rate of HIV transmission by nearly 70%. In one study, couples with one infected partner who used condoms inconsistently had a considerable risk of infection: the rate of seroconversion was estimated to be 13% after 24 months. No seroconversions were noted with consistent condom use. Unfortunately, as many as one-third of HIV-positive persons continue unprotected sexual practices after learning that they are HIV-infected. Tailored group educational intervention focused on practicing “safer sex” can reduce their transmission-risk behaviors with partners who are not HIV-positive. Other approaches to prevent HIV infection include treatment of sexually transmitted diseases, development of vaginal microbicides, and vaccine development. Increasingly, cases of HIV infection are transmitted by injection drug use. HIV prevention activities should include provision of sterile injection equipment for these individuals.

With regard to secondary prevention, many HIV-infected persons in the United States receive the diagnosis at advanced stages of immunosuppression, and almost all will progress to AIDS if untreated. On the other hand, HAART substantially reduces the risk of clinical progression or death in patients with advanced immunosuppression. Screening tests for HIV are extremely (> 99%) accurate. While the benefits of HIV screening appear to outweigh its harms, current screening is generally based on individual patient risk factors. Such screening can identify persons at risk for AIDS but misses a substantial proportion of those infected. Nonetheless, the yield from screening higher prevalence populations is substantially greater than that from screening the general population, and more widespread screening of the population remains controversial.

In immunocompromised patients, live vaccines are contraindicated but many killed or component vaccines are safe and recommended. Asymptomatic HIV-infected patients have not shown adverse consequences when given live MMR and influenza vaccinations as well as tetanus, hepatitis B, H influenza type b and pneumococcal vaccinations—all should be given. However, if poliomyelitis immunization is required, the inactivated poliomyelitis vaccine is indicated. In symptomatic HIV-infected patients, live virus vaccines such as MMR should generally be avoided, but annual influenza vaccination is safe.

Whenever possible, immunizations should be completed before procedures that require or induce immunosuppression (organ transplantation or chemotherapy), or that reduce immunogenic responses (splenectomy). However, if this is not possible, the patient may mount only a partial immune response, yet even this partial response can be beneficial. Patients who undergo allogeneic bone marrow transplantation lose preexisting immunities and should be revaccinated. In many situations, family members should also be vaccinated to protect the immunocompromised patient, although oral live polio vaccine should be avoided because of the risk of infecting the patient.

New cases of poliomyelitis have been reported in the United States, Haiti, and the Dominican Republic recently, slowing its eradication in the Western Hemisphere. Worldwide eradication of poliovirus, including endemic areas such as India, remains challenging.

During March and April 2009, a new influenza A (H1N1) virus was determined to be the cause of an outbreak of respiratory illness in Mexico; during the same time, two children in the United States became infected with the same virus. By June 2009, the World Health Organization (WHO) declared a worldwide pandemic. In August 2010, the WHO International Health Regulations Emergency Committee declared an end to the 2009 H1N1 pandemic globally.

Herpes zoster, caused by reactivation from previous varicella zoster virus (VZV) infection, affects many older adults and people with immune system dysfunction. Whites are at higher risk than other ethnic groups and the incidence in adults age 65 and older may be higher than previously described. It can cause postherpetic neuralgia, a potentially debilitating chronic pain syndrome. A varicella vaccine is available for the prevention of herpes zoster. Several clinical trials have shown that this vaccine (Zostavax) is safe, elevates VZV-specific cell-mediated immunity, and significantly reduces the incidence of herpes zoster and postherpetic neuralgia in persons older than 60 years. In one randomized, double-blind, placebo-controlled trial among more than 38,000 older adults, the vaccine reduced the incidence of postherpetic neuralgia by 66% and the incidence of herpes zoster by 51%. The ACIP recommends routine zoster vaccination, administered as a one-time subcutaneous dose (0.65 mL), of all persons aged 60 years or older. Persons who report a previous episode of zoster can be vaccinated; however, the vaccine is contraindicated in immunocompromised (primary or acquired) individuals. The durability of vaccine response and whether any booster vaccination is needed are still uncertain. The cost effectiveness of the vaccine varies substantially, and the patient's age should be considered in vaccine recommendations. One study reported a cost-effectiveness exceeding $100,000 per quality-adjusted life year saved. Despite its availability, uptake of the vaccine remains low at 2–7% nationally. Financial barriers (cost, limited knowledge of reimbursement) have had a significant impact on its underutilization.

In 2008, the United States Preventive Services Task Force (USPSTF) reviewed evidence to reaffirm its recommendation on limiting screening for asymptomatic bacteriuria in adults. New evidence was reviewed, which continues to support routine screening in pregnant women but not in other groups of adults.

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Chaves SS et al. Chickenpox exposure and herpes zoster disease incidence in older adults in the U.S. Public Health Rep. 2007 Mar–Apr;122(2):155–9. [PMID: 17357357]



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PREVENTION OF CARDIOVASCULAR DISEASE


Cardiovascular diseases, including coronary heart disease (CHD) and stroke, represent two of the most important causes of morbidity and mortality in developed countries. Several risk factors increase the risk for coronary disease and stroke. These risk factors can be divided into those that are modifiable (eg, lipid disorders, hypertension, cigarette smoking) and those that are not (eg, gender, age, family history of early coronary disease). Impressive declines in age-specific mortality rates from heart disease and stroke have been achieved in all age groups in North America during the past two decades, in large part through improvement of modifiable risk factors: reductions in cigarette smoking, improvements in lipid levels, and more aggressive detection and treatment of hypertension. This section considers the role of screening for cardiovascular risk and the use of effective therapies to reduce such risk. Key recommendations for cardiovascular prevention are shown in Table 1–3.

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Abdominal Aortic Aneurysm


One-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65–75 years is associated with a significant reduction in AAA-related mortality (odds ratio, 0.56 [95% CI, 0.44 to 0.72]). With long-term (7-15 years) follow-up, the reduction in AAA-related mortality is sustained, and screening appears to produce a reduction in all-cause mortality (OR = 0.94, 95% CI 0.92, 0.97). Women do not appear to benefit from screening, and most of the benefit in men appears to accrue among current or former smokers. Recent analyses suggest that screening men aged 65 years and older is highly cost-effective.

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Cigarette Smoking


Cigarette smoking remains the most important cause of preventable morbidity and early mortality. In 2000, there were an estimated 4.8 million premature deaths in the world attributable to smoking, 2.4 million in developing countries and 2 million in industrialized countries. More than three-quarters (3.8 million) of these deaths were in men. The leading causes of death from smoking were cardiovascular diseases (1.7 million deaths), chronic obstructive pulmonary disease (COPD) (1 million deaths), and lung cancer (0.9 million deaths). Cigarettes are responsible for one in every four deaths in the United States. Fortunately, US smoking rates are declining. Currently, 20% of US adults and 21.6% of adolescents in 12th grade are smokers.



Table 1–3 Expert recommendations for cardiovascular prevention methods: US Preventive Services Task Force (USPSTF).1





Prevention Method

Recommendation

Screening for abdominal aortic aneurysm

Recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked. (B)

No recommendation for or against screening for AAA in men aged 65 to 75 who have never smoked. (C)

Recommends against routine screening for AAA in women. (D)



Aspirin use

Recommends the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. (A)

Recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. (A)

Current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older. (I)

Recommends against the use of aspirin for stroke prevention in women younger than 55 years and for myocardial infarction prevention in men younger than 45.



Blood pressure screening

Recommends screening for high blood pressure in adults aged 18 and older. (A)



Serum lipid screening

Strongly recommends screening men aged 35 and older for lipid disorders. (A)

Recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. (B)

Strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. (A)

Recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. (B)

No recommendation for or against routine screening for lipid disorders in men aged 20 to 35, or in women aged 20 and older who are not at increased risk for coronary heart disease. (C)



Counseling about healthy diet

Evidence is insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in unselected patients in primary care settings. (I)

Recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians. (B)



Screening for diabetes

Recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) > 135/80 mm Hg. (B)

Current evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or lower. (I)



Counseling to promote physical activity

Evidence is insufficient to recommend for or against behavioral counseling in primary care settings to promote physical activity. (I)



Screening for smoking and counseling to promote cessation

Recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. (A)





1Recommendation A: The USPSTF strongly recommends that clinicians routinely provide the service to eligible patients. (The USPSTF found good evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms.)

Recommendation B: The USPSTF recommends that clinicians routinely provide the service to eligible patients. (The USPSTF found at least fair evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms.)

Recommendation C: The USPSTF makes no recommendation for or against routine provision of the service.

Recommendation D: The USPSTF recommends against routinely providing the service to asymptomatic patients. (The USPSTF found at least fair evidence that the service is ineffective or that harms outweigh benefits.)

Recommendation I: The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service. http://www.uspreventiveservicestaskforce.org/ 3rduspstf/ratings.htm

Nicotine is highly addictive, raises brain levels of dopamine, and produces withdrawal symptoms on discontinuation.

Smokers die 5–8 years earlier than never-smokers. They have twice the risk of fatal heart disease, 10 times the risk of lung cancer, and several times the risk of cancers of the mouth, throat, esophagus, pancreas, kidney, bladder, and cervix; a twofold to threefold higher incidence of stroke and peptic ulcers (which heal less well than in nonsmokers); a twofold to fourfold greater risk of fractures of the hip, wrist, and vertebrae; four times the risk of invasive pneumococcal disease; and a twofold increase in cataracts.

In the United States, over 90% of cases of COPD occur among current or former smokers. Both active smoking and passive smoking are associated with deterioration of the elastic properties of the aorta (increasing the risk of aortic aneurysm) and with progression of carotid artery atherosclerosis. Smoking has also been associated with increased risks of leukemia, of colon and prostate cancers, of breast cancer among postmenopausal women who are slow acetylators of N-acetyltransferase-2 enzymes, osteoporosis, and Alzheimer disease. In cancers of the head and neck, lung, esophagus, and bladder, smoking is linked to mutations of the P53 gene, the most common genetic change in human cancer. Patients with head and neck cancer who continue to smoke during radiation therapy have lower rates of response than those who do not smoke. Olfaction and taste are impaired in smokers, and facial wrinkles are increased. Heavy smokers have a 2.5 greater risk of age-related macular degeneration.

The children of smokers have lower birth weights, are more likely to be mentally retarded, have more frequent respiratory infections and less efficient pulmonary function, have a higher incidence of chronic ear infections than children of nonsmokers, and are more likely to become smokers themselves.

In addition, exposure to environmental tobacco smoke has been shown to increase the risk of cervical cancer, lung cancer, invasive pneumococcal disease, and heart disease; to promote endothelial damage and platelet aggregation; and to increase urinary excretion of tobacco-specific lung carcinogens. The incidence of breast cancer may be increased as well. Of approximately 450,000 smoking-related deaths in the United States annually, as many as 53,000 are attributable to environmental tobacco smoke. Annual costs of smoking-related health care is approximately $96 billion per year in the United States, with another $97 billion in productivity losses.

Smoking cessation reduces the risks of death and of myocardial infarction in people with coronary artery disease; reduces the rate of death and acute myocardial infarction in patients who have undergone percutaneous coronary revascularization; lessens the risk of stroke; slows the rate of progression of carotid atherosclerosis; and is associated with improvement of COPD symptoms. On average, women smokers who quit smoking by age 35 add about 3 years to their life expectancy, and men add more than 2 years to theirs. Smoking cessation can increase life expectancy even for those who stop after the age of 65.

Although tobacco use constitutes the most serious common medical problem, it is undertreated. Almost 40% of smokers attempt to quit each year, but only 4% are successful. Persons whose clinicians advise them to quit are 1.6 times as likely to attempt quitting. Over 70% of smokers see a physician each year, but only 20% of them receive any medical quitting advice or assistance.

Factors associated with successful cessation include having a rule against smoking in the home, being older, and having greater education. Several effective interventions are available to promote smoking cessation, including counseling, pharmacotherapy, and combinations of the two. The five steps for helping smokers quit are summarized in Table 1–4.

Common elements of supportive smoking cessation treatments are reviewed in Table 1–5. A system should be implemented to identify smokers, and advice to quit should be tailored to the patient's level of readiness to change. Pharmacotherapy to reduce cigarette consumption is ineffective in smokers who are unwilling or not ready to quit. Conversely, all patients trying to quit should be offered pharmacotherapy except those with medical contraindications, women who are pregnant or breast-feeding, and adolescents. Weight gain occurs in most patients (80%) following smoking cessation. For many, it averages 2 kg, but for others (10–15%) major weight gain—over 13 kg—may occur. Planning for the possibility of weight gain, and means of mitigating it, may help with maintenance of cessation.

Several pharmacologic therapies have been shown to be effective in promoting cessation. Nicotine replacement therapy doubles the chance of successful quitting. The nicotine patch, gum, and lozenges are available over-the-counter, and nicotine nasal spray and inhalers by prescription. The sustained-release antidepressant drug bupropion (150–300 mg/d orally) is an effective smoking cessation agent and is associated with minimal weight gain, although seizures are a contraindication. It acts by boosting brain levels of dopamine and norepinephrine, mimicking the effect of nicotine. More recently, varenicline, a partial nicotinic acetylcholine-receptor agonist, has been shown to improve cessation rates; however, its adverse effects, particularly its effects on mood, are not incompletely understood and warrant careful use. No single pharmacotherapy is clearly more effective than others, so patient preferences should be taken into account in selecting a treatment.

Clinicians should not show disapproval of patients who failed to stop smoking or who are not ready to make a quit attempt. Thoughtful advice that emphasizes the benefits of cessation and recognizes common barriers to success can increase motivation to quit and quit rates. An intercurrent illness such as acute bronchitis or acute myocardial infarction may motivate even the most addicted smoker to quit.

Individualized or group counseling is very cost-effective, even more so than treating hypertension. Smoking cessation counseling by telephone (“quitlines”) has proved effective. An additional strategy is to recommend that any smoking take place out of doors to limit the effects of passive smoke on housemates and coworkers. This can lead to smoking reduction and quitting.



Table 1–4 Actions and strategies for the primary care clinician to help patients quit smoking.





Action

Strategies for Implementation

Step 1. Ask—Systematically Identify All Tobacco Users at Every Visit

Implement an officewide system that ensures that for every patient at every clinic visit, tobacco-use status is queried and documented1

Expand the vital signs to include tobacco use.

Data should be collected by the health care team.

The action should be implemented using preprinted progress note paper that includes the expanded vital signs, a vital signs stamp or, for computerized records, an item assessing tobacco-use status.

Alternatives to the vital signs stamp are to place tobacco-use status stickers on all patients’ charts or to indicate smoking status using computerized reminder systems.



Step 2. Advise—Strongly Urge All Smokers to Quit

In a clear, strong, and personalized manner, urge every smoker to quit

Advice should be

Clear “I think it is important for you to quit smoking now, and I will help you. Cutting down while you are ill is not enough.”

Strong “As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your current and future health.”

Personalized Tie smoking to current health or illness and/or the social and economic costs of tobacco use, motivational level/readiness to quit, and the impact of smoking on children and others in the household.

Encourage clinic staff to reinforce the cessation message and support the patient's quit attempt.



Step 3. Attempt—Identify Smokers Willing to Make a Quit Attempt

Ask every smoker if he or she is willing to make a quit attempt at this time

If the patient is willing to make a quit attempt at this time, provide assistance (see step 4).

If the patient prefers a more intensive treatment or the clinician believes more intensive treatment is appropriate, refer the patient to interventions administered by a smoking cessation specialist and follow up with him or her regarding quitting (see step 5).

If the patient clearly states he or she is not willing to make a quit attempt at this time, provide a motivational intervention.



Step 4. Assist—Aid the Patient in Quitting

A. Help the patient with a quit plan

Set a quit date. Ideally, the quit date should be within 2 weeks, taking patient preference into account.

Help the patient prepare for quitting. The patient must:

Inform family, friends, and coworkers of quitting and request understanding and support.

Prepare the environment by removing cigarettes from it. Prior to quitting, the patient should avoid smoking in places where he or she spends a lot of time (eg, home, car).

Review previous quit attempts. What helped? What led to relapse?

Anticipate challenges to the planned quit attempt, particularly during the critical first few weeks.



B. Encourage nicotine replacement therapy except in special circumstances

Encourage the use of the nicotine patch or nicotine gum therapy for smoking cessation



C. Give key advice on successful quitting

Abstinence Total abstinence is essential. Not even a single puff after the quit date.

Alcohol Drinking alcohol is highly associated with relapse. Those who stop smoking should review their alcohol use and consider limiting or abstaining from alcohol use during the quit process.

Other smokers in the household: The presence of other smokers in the household, particularly a spouse, is associated with lower success rates. Patients should consider quitting with their significant others and/or developing specific plans to maintain abstinence in a household where others still smoke.



D. Provide supplementary materials

Source Federal agencies, including the National Cancer Institute and the Agency for Health Care Policy and Research; nonprofit agencies (American Cancer Society, American Lung Association, American Heart Association); or local or state health departments.

Selection concerns: The material must be culturally, racially, educationally, and age appropriate for the patient.

Location Readily available in every clinic office.



Step 5. Arrange—Schedule Follow-Up Contact

Schedule follow-up contact, either in person or via telephone1

Timing Follow-up contact should occur soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Schedule further follow-up contacts as indicated.

Actions during follow-up: Congratulate success. If smoking occurred, review the circumstances and elicit recommitment to total abstinence. Remind the patient that a lapse can be used as a learning experience and is not a sign of failure. Identify the problems already encountered and anticipate challenges in the immediate future. Assess nicotine replacement therapy use and problems. Consider referral to a more intense or specialized program.





1Repeated assessment is not necessary in the case of the adult who has never smoked or not smoked for many years and for whom the information is clearly documented in the medical record.

Adapted and reproduced, with permission, from: The Agency for Health Care Policy and Research. Smoking Cessation Clinical Practice Guideline. JAMA. 1996 Apr 24;275(16):1270–80. Copyright © 1996 American Medical Association. All rights reserved.

The clinician's role in smoking cessation is summarized in Table 1–4. Public policies, including higher cigarette taxes and more restrictive public smoking laws, have also been shown to encourage cessation, as have financial incentives directed to patients.



Table 1–5. Common elements of supportive smoking treatments.





Component

Examples

Encouragement of the patient in the quit attempt

Note that effective cessation treatments are now available.

Note that half the people who have ever smoked have now quit.

Communicate belief in the patient's ability to quit.



Communication of caring and concern

Ask how the patient feels about quitting.

Directly express concern and a willingness to help.

Be open to the patient's expression of fears of quitting, difficulties experienced, and ambivalent feelings.



Encouragement of the patient to talk about the quitting process

Ask about:

Reasons that the patient wants to quit.

Difficulties encountered while quitting.

Success the patient has achieved.

Concerns or worries about quitting.



Provision of basic information about smoking and successful quitting

Inform the patient about:

The nature and time course of withdrawal.

The addictive nature of smoking.

The fact that any smoking (even a single puff) increases the likelihood of full relapse.





Adapted, with permission, from: The Agency for Health Care Policy and Research. Smoking Cessation Clinical Practice Guideline. JAMA. 1996 Apr 24;275(16):1270–80. Copyright © 1996 American Medical Association. All rights reserved.

Centers for Disease Control and Prevention (CDC). Smoking-attributable mortality, years of potential life lost, and productivity losses–United States, 2000–2004. MMWR Morb Mortal Wkly Rep. 2008 Nov 14;57(45):1226–8. [PMID: 19008791]



Eisenberg MJ et al. Pharmacotherapies for smoking cessation: a meta-analysis of randomized controlled trials. CMAJ. 2008 Jul 15;179(2):135–44. [PMID: 18625984]



Lee CW et al. Factors associated with successful smoking cessation in the United States, 2000. Am J Public Health. 2007 Aug; 97(8):1503–9. [PMID: 17600268]



Moore D et al. Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smok