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In This Issue of Archives of Internal Medicine |

In This Issue of Archives of Internal Medicine FREE

Arch Intern Med. 2003;163(5):517. doi:10.1001/archinte.163.5.517.
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GENETIC COUNSELING AND TESTING IN FAMILIES WITH HEREDITARY NONPOLYPOSIS COLORECTAL CANCER

Little is known about the factors influencing the uptake of testing for the most common hereditary colon cancer, hereditary nonpolyposis colorectal cancer. Genetic counseling and testing offers the potential to focus cancer screening, reducing mortality and morbidity. However, fears of discrimination and concerns about psychological and psychosocial issues may present barriers to appropriate utilization of current cancer prevention strategies including genetic counseling and testing. This study examines attitudes, intentions, and uptake of genetic testing within newly identified families with hereditary nonpolyposis colorectal cancer.

THE VALUE OF DISEASE SEVERITY IN PREDICTING PATIENT READINESS TO ADDRESS END-OF-LIFE ISSUES

Patients and physicians agree that direct discussion is the most important tool for addressing end-of-life medical care. However, physicians struggle to know when to initiate such discussions, fearing patients are not ready for them. Too often the discussions are never held and surrogate decision making is required. This study evaluates the association of intensity of recent care and objective measures of severity in chronic lung disease with patient readiness for end-of-life discussions. Patient readiness for discussion was not associated with decreased percentage of predicted FEV1, the required use of oral corticosteroids or mechanical ventilation, lower functional status, or more frequent recent hospitalizations. Individual characteristics and values of patients appear to outweigh objective clinical data or experiences in determining readiness. Focusing on physician skill in using specific communication strategies for patients at all stages of illness may be the most promising approach to increasing end-of-life discussions.

CHALLENGES TO THE EFFECTIVE USE OF UNFRACTIONATED HEPARIN IN THE HOSPITALIZED MANAGEMENT OF ACUTE THROMBOSIS

In this study, the authors define the real-world course of anticoagulation among hospitalized patients treated for acute venous or arterial thrombosis at their medical center. The study highlights the difficulties intrinsic to the use of intravenous heparin among medically complex patients and raises issues pertaining to the quality of anticoagulant care.

MANAGEMENT OF HIGH BLOOD PRESSURE IN AFRICAN AMERICANS

The need for specific recommendations for managing high blood pressure in African Americans is highlighted by compelling evidence of poorer cardiovascular and renal outcomes in this group compared with white Americans. With this consensus statement, the Hypertension in African Americans Working Group provides primary care providers with a practical, evidence-based clinical tool for achieving blood pressure goals in African American patients. Barriers to normalizing blood pressure in African Americans are too often attributed to biological and social factors, with an inadequate focus on the role of medical management. Simply stated, a key obstacle is the failure of medical providers to treat high blood pressure early and persistently to an appropriate blood pressure target. A new approach is needed to reduce the adverse outcomes associated with high blood pressure in African Americans. Traditional strategies (eg, accepting blood pressure levels above target goals, titrating to high-dose monotherapy, and avoiding specific classes of antihypertensive medications) have proved unsuccessful. The "best practice" strategies described in this article are intended to achieve efficacy in blood pressure reduction in tandem with protection against target-organ damage. These strategies involve assessing cardiovascular risk; setting, achieving, and maintaining an appropriate blood pressure target; assisting patients to implement therapeutic lifestyle changes; and initiating effective pharmacologic interventions early and persistently.

FLUOROQUINOLONE UTILIZATION IN THE EMERGENCY DEPARTMENTS OF ACADEMIC MEDICAL CENTERS

Resistance to fluoroquinolone antibiotics has risen markedly in recent years and has been associated with increasing use of these agents. Although designing strategies to limit fluoroquinolone resistance by optimizing fluoroquinolone use depends on identifying patterns of inappropriate utilization of these agents, few data exist regarding fluoroquinolone use patterns. In this study, Lautenbach et al found that in more than 80% of patients who received a fluoroquinolone in 2 academic emergency departments, the indication for use was not appropriate when judged by established institutional guidelines. In those patients for whom the indication for a fluoroquinolone was appropriate, either the dose or the duration of fluoroquinolone was nearly always incorrect. Efforts to limit emergence of fluoroquinolone resistance must address the high level of inappropriate fluoroquinolone use in emergency departments.

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Appropriateness of fluoroquinolone use by site of infection.

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Appropriateness of fluoroquinolone use by site of infection.

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