To review the pathophysiology of gastrointestinal motility disorders during pregnancy, their clinical manifestations, and their management.

To review the literature on the utility of fine-needle aspiration biopsy in the diagnostic management of nodular thyroid disease.

For many older persons, hospitalization results in functional decline despite cure or repair of the condition for which they were admitted. Hospitalization can result in complications unrelated to the problem that caused admission or to its specific treatment for reasons that are explainable and avoidable. Usual aging is often associated with functional change, such as a decline in muscle strength and aerobic capacity; vasomotor instability; reduced bone density; diminished pulmonary ventilation; altered sensory continence, appetite, and thirst; and a tendency toward urinary incontinence. Hospitalization and bed rest superimpose factors such as enforced immobilization, reduction of plasma volume, accelerated bone loss, increased closing volume, and sensory deprivation. Any of these factors may thrust vulnerable older persons into a state of irreversible functional decline. The factors that contribute to a cascade to dependency are identifiable and can be avoided by modification of the usual acute hospital environment by deemphasizing bed rest, removing the hazard of the high hospital bed with rails, and actively facilitating ambulation and socialization. The relationships among physicians, nurses, and other health professionals must reflect the importance of interdisciplinary care and the implementation of shared objectives.

To review the principles of multivariable analysis and to examine the application of multivariable statistical methods in general medical literature.

To review the clinical, epidemiologic, and biological features of infection with the human immunodeficiency virus type 2 (HIV-2).

The approximately 1.2 million inmates in U.S. correctional institutions have a high prevalence of communicable diseases, such as human immunodeficiency virus (HIV) infection, tuberculosis, hepatitis B virus infection, and gonorrhea. Before their incarceration, most inmates had limited access to health care, which, together with poor compliance because of lifestyle, made them difficult to identify and treat in the general community. Because of the high yearly turnover (approximately 800% and 50% in jails and prisons, respectively), the criminal justice system can play an important public health role both during incarceration and in the immediate postrelease period. A public policy agenda for criminal justice should include an epidemiologic orientation, as well as resources for education, counseling, early detection, and treatment. Taking advantage of the period of confinement would serve both the individual and society by controlling communicable diseases in large urban communities.

To assess the relative effect of different antihypertensive agents on proteinuria and renal function in patients with diabetes.

To review reports on the transmission of infections by flexible gastrointestinal endoscopy and bronchoscopy in order to determine common infecting microorganisms, circumstances of transmission, and methods of risk reduction.

Epstein-Barr virus (EBV) encodes genes that ensure its persistence in human B lymphocytes. Some of the genes encourage B-cell proliferation; others are poised to evade or defeat immune recognition. Immune restraints on the virus, however, are typically so effective that most infections are never symptomatic. In contrast, acute infectious mononucleosis, a self-limited lymphoproliferative illness, is common in adolescents and young adults. Unbridled proliferative illnesses arise when cellular immunity is grossly defective. Treatment of EBV-associated syndromes is largely supportive. Antiviral drugs have no proven role except in patients with oral hairy leukoplakia. Vaccine development is technically feasible but is not considered a high priority for developed nations.

To critically review the risks and benefits of hormone therapy for asymptomatic postmenopausal women who are considering long-term hormone therapy to prevent disease or to prolong life.

To present the case of a Jehovah's Witness with severe anemia and to review the religious philosophy of such patients, the ethical and medicolegal aspects of their care, and the therapeutic options available to clinicians.

Medicine, law, and social values are not static and must be re-examined periodically. This edition of the ACP Ethics Manual covers emerging issues in medical ethics and revisits some old issues. The overview of the evolution of medical ethics, which appeared in previous editions of the Manual, has been eliminated to allow more space for the consideration of today's ethical dilemmas. Other changes include a revised chapter on end-of-life care, discussion of physician-assisted suicide, revised sections on conflicts of interest and on medical risk to the physician and patient, given developments in human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS), and discussion of sexual contact between physician and patient. A statement on disclosure of errors and a section on care of the physician's family have also been added. The sections on confidential information told by a patient's family or friend to the physician; on physician-pharmaceutical industry relations; on physicians in training; and on the impaired physician have been expanded. Sections on advertising, peer review, and resource allocation have been revised. The literature of biomedical ethics expands at a rate that does not allow a bibliography to remain current, so an exhaustive list of references or suggested readings is not included in this manual. Instead, only cited references are listed.

To review the clinical, epidemiologic, immunologic, and virologic aspects of the chronic myelopathy associated with human T-cell leukemia/lymphoma virus type I (HTLV-I), currently called tropical spastic paraparesis/HTLV-I-associated myelopathy (TSP/HAM).

To review the current role of transesophageal echocardiography in the evaluation of stroke.

The molecular and biochemical bases for interactions between the immune and central nervous systems are described. Immune cytokines not only activate immune function but also recruit central stress-responsive neurotransmitter systems in the modulation of the immune response and in the activation of behaviors that may be adaptive during injury or inflammation. Peripherally generated cytokines, such as interleukin-1, signal hypothalamic corticotropin-releasing hormone (CRH) neurons to activate pituitary-adrenal counter-regulation of inflammation through the potent antiinflammatory effects of glucocorticoids. Corticotropin-releasing hormone not only activates the pituitary-adrenal axis but also sets in motion a coordinated series of behavioral and physiologic responses, suggesting that the central nervous system may coordinate both behavioral and immunologic adaptation during stressful situations. The pathophysiologic perturbation of this feedback loop, through various mechanisms, results in the development of inflammatory syndromes, such as rheumatoid arthritis, and behavioral syndromes, such as depression. Thus, diseases characterized by both inflammatory and emotional disturbances may derive from common alterations in specific central nervous system pathways (for example, the CRH system). In addition, disruptions of this communication by genetic, infectious, toxic, or pharmacologic means can influence the susceptibility to disorders associated with both behavioral and inflammatory components and potentially alter their natural history. These concepts suggest that neuropharmacologic agents that stimulate hypothalamic CRH might potentially be adjunctive therapy for illnesses traditionally viewed as inflammatory or autoimmune.

To review recent advances in detecting renovascular hypertension.

The Federated Council for Internal Medicine (FCIM) comprises the American Board of Internal Medicine, American College of Physicians, American Society of Internal Medicine, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, and the Society of General Internal Medicine. The Council was established in 1975 to speak with a collective voice for the specialty of internal medicine. In 1992, the Council developed the following statement in conjunction with its endorsement of a target of 50% of internal medicine residency graduates entering the practice of general internal medicine.

The natural history and current management of carcinoma of the breast in men is reviewed. Articles published from 1942 to 1992 on the natural history, clinical manifestations, diagnosis, and treatment of carcinoma of the breast in men were identified using CANCERLINE and MEDLINE. Carcinoma of the breast affects approximately 1000 men per year in the United States; 300 men per year will die of metastatic disease. The mean age at diagnosis is 59 years. The causes of breast cancer in men are unknown. The most common clinical manifestation of breast cancer in men is a painless, firm subareolar mass or a mass in the upper outer quadrant of the breast. Diagnosis can be confirmed by fine-needle aspiration or surgical biopsy. Infiltrating ductal carcinoma is the predominant histologic type. Treatment is similar to that of women with breast cancer. Men with axillary nodal metastasis should receive adjuvant systemic combination chemotherapy or tamoxifen, or both, after primary surgical treatment. Because most men with carcinoma of the breast have estrogen- and progesterone-receptor-positive tumors, distant metastatic disease should be treated initially with hormonal therapies. The epidemiology, prognostic factors, survival by stage, pattern of metastasis, and response to treatment in men are similar to those in women with breast carcinoma. The data suggest, however, that breast cancers in men are more likely to respond to hormonal manipulation.

Premature ventricular complexes (PVCs) can provide clues to the physical or electrocardiographic diagnosis through the associated compensatory pause, the break in the regularity of the rhythm, or the morphology of the PVC itself. A PVC may allow visualization of the P wave or of atrial flutter waves that would otherwise be obscured in the electrocardiogram. It can also be useful in distinguishing an S3 gallop from an S4 gallop. The compensatory pause that follows a PVC may allow normal conduction of the next QRS complex in a patient with a rate-dependent intraventricular conduction defect, and this normalized QRS complex may contain important diagnostic findings. A PVC can also reveal a myocardial infarct pattern when the sinus complex fails to do so. Although the need to treat PVCs is currently being de-emphasized, their diagnostic utility should not be overlooked.