The management of patients with acute nonvariceal upper gastrointestinal bleeding has evolved substantially over the past 10 years amid a paucity of published consensus guidelines.

Chronic kidney disease is a worldwide public health problem with an increasing incidence and prevalence, poor outcomes, and high cost. Outcomes of chronic kidney disease include not only kidney failure but also complications of decreased kidney function and cardiovascular disease. Current evidence suggests that some of these adverse outcomes can be prevented or delayed by early detection and treatment. Unfortunately, chronic kidney disease is underdiagnosed and undertreated, in part as a result of lack of agreement on a definition and classification of its stages of progression. Recent clinical practice guidelines by the National Kidney Foundation 1) define chronic kidney disease and classify its stages, regardless of underlying cause, 2) evaluate laboratory measurements for the clinical assessment of kidney disease, 3) associate the level of kidney function with complications of chronic kidney disease, and 4) stratify the risk for loss of kidney function and development of cardiovascular disease. The guidelines were developed by using an approach based on the procedure outlined by the Agency for Healthcare Research and Quality. This paper presents the definition and five-stage classification system of chronic kidney disease and summarizes the major recommendations on early detection in adults. Recommendations include identifying persons at increased risk (those with diabetes, those with hypertension, those with a family history of chronic kidney disease, those older than 60 years of age, or those with U.S. racial or ethnic minority status), detecting kidney damage by measuring the albumin-creatinine ratio in untimed ("spot") urine specimens, and estimating the glomerular filtration rate from serum creatinine measurements by using prediction equations. Because of the high prevalence of early stages of chronic kidney disease in the general population (approximately 11% of adults), this information is particularly important for general internists and specialists.

This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on routine vitamin supplementation to prevent cancer and cardiovascular disease and the supporting scientific evidence. Part of the information on which this statement is based, including evidence tables and references, is available in the accompanying article on vitamins to prevent cardiovascular disease in this issue. More complete information can be found in the summaries of the evidence on vitamins to prevent cancer and vitamins to prevent cardiovascular disease, available on the USPSTF Web site (http://www.preventiveservices.ahrq.gov) and through the National Guideline Clearinghouse (http://www.guideline.gov). The summaries of the evidence on these topics and the recommendation statement are also available in print through subscription to the Guide to Clinical Preventive Services, Third Edition: Periodic Updates. A subscription costs $60 U.S. and can be ordered through the Agency for Healthcare Research and Quality Publications Clearinghouse (call 800-358-9295 or e-mail mailto:ahrqpubs@ahrq.gov).

This paper is part 1 of a 2-part series on interpretation of 12-lead resting electrocardiograms (ECGs). Part 1 is a position paper that presents recommendations for initial competency, competency assessment, and maintenance of competency on ECG interpretation, as well as recommendations for the role of computer-assisted ECG interpretation. Part 2 is a systematic review of detailed supporting evidence for the recommendations. Despite several earlier consensus-based recommendations on ECG interpretation, substantive evidence on the training needed to obtain and maintain ECG interpretation skills is not available. Some studies show that noncardiologist physicians have more ECG interpretation errors than do cardiologists, but the rate of adverse patient outcomes from ECG interpretation errors is low. Computers may decrease the time needed to interpret ECGs and can reduce ECG interpretation errors. However, they have shown less accuracy than physician interpreters and must be relied on only as an adjunct interpretation tool for a trained provider. Interpretation of ECGs varies greatly, even among expert electrocardiographers. Noncardiologists seem to be more influenced by patient history in interpreting ECGs than are cardiologists. Cardiologists also perform better than other specialists on standardized ECG examinations when minimal patient history is provided. Pending more definitive research, residency training in internal medicine with Advanced Cardiac Life Support instruction should continue to be sufficient for bedside interpretation of resting 12-lead ECGs in routine and emergency situations. Additional experience or training in ECG interpretation when the patient's clinical condition is unknown may be useful but requires further study.

In 1995, the U.S. Public Health Service (USPHS) and the Infectious Diseases Society of America (IDSA) developed guidelines for preventing opportunistic infections (OIs) among persons infected with human immunodeficiency virus (HIV); these guidelines were updated in 1997 and 1999. This fourth edition of the guidelines, made available on the Internet in 2001, is intended for clinicians and other health-care providers who care for HIV-infected persons. The goal of these guidelines is to provide evidence-based guidelines for preventing OIs among HIV-infected adults and adolescents, including pregnant women, and HIV-exposed or infected children. Nineteen OIs, or groups of OIs, are addressed, and recommendations are included for preventing exposure to opportunistic pathogens, preventing first episodes of disease by chemoprophylaxis or vaccination (primary prophylaxis), and preventing disease recurrence (secondary prophylaxis). Major changes since the last edition of the guidelines include 1) updated recommendations for discontinuing primary and secondary OI prophylaxis among persons whose CD4+ T lymphocyte counts have increased in response to antiretroviral therapy; 2) emphasis on screening all HIV-infected persons for infection with hepatitis C virus; 3) new information regarding transmission of human herpesvirus 8 infection; 4) new information regarding drug interactions, chiefly related to rifamycins and antiretroviral drugs; and 5) revised recommendations for immunizing HIV-infected adults and adolescents and HIV-exposed or infected children.

The availability of an increasing number of antiretroviral agents and the rapid evolution of new information have introduced substantial complexity into treatment regimens for persons infected with human immunodeficiency virus (HIV). In 1996, the Department of Health and Human Services and the Henry J. Kaiser Family Foundation convened the Panel on Clinical Practices for the Treatment of HIV to develop guidelines for clinical management of HIV-infected adults and adolescents (CDC. Report of the NIH Panel To Define Principles of Therapy of HIV Infection and Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. MMWR. 1998;47[RR-5]:1-41). This report, which updates the 1998 guidelines, addresses 1) using testing for plasma HIV ribonucleic acid levels (i.e., viral load) and CD4+ T cell count; 2) using testing for antiretroviral drug resistance; 3) considerations for when to initiate therapy; 4) adherence to antiretroviral therapy; 5) considerations for therapy among patients with advanced disease; 6) therapy-related adverse events; 7) interruption of therapy; 8) considerations for changing therapy and available therapeutic options; 9) treatment for acute HIV infection; 10) considerations for antiretroviral therapy among adolescents; 11) considerations for antiretroviral therapy among pregnant women; and 12) concerns related to transmission of HIV to others. Antiretroviral regimens are complex, have serious side effects, pose difficulty with adherence, and carry serious potential consequences from the development of viral resistance because of nonadherence to the drug regimen or suboptimal levels of antiretroviral agents. Patient education and involvement in therapeutic decisions are critical. Treatment should usually be offered to all patients with symptoms ascribed to HIV infection. Recommendations for offering antiretroviral therapy among asymptomatic patients require analysis of real and potential risks and benefits. In general, treatment should be offered to persons who have <350 CD4+ T cells/mm3 or plasma HIV ribonucleic acid (RNA) levels of >55,000 copies/mL (by b-deoxyribonucleic acid [bDNA] or reverse transcriptase-polymerase chain reaction [RT-PCR] assays). The recommendation to treat asymptomatic patients should be based on the willingness and readiness of the person to begin therapy; the degree of existing immunodeficiency as determined by the CD4+ T cell count; the risk for disease progression as determined by the CD4+ T cell count and level of plasma HIV RNA; the potential benefits and risks of initiating therapy in an asymptomatic person; and the likelihood, after counseling and education, of adherence to the prescribed treatment regimen. Treatment goals should be maximal and durable suppression of viral load, restoration and preservation of immunologic function, improvement of quality of life, and reduction of HIV-related morbidity and mortality. Results of therapy are evaluated through plasma HIV RNA levels, which are expected to indicate a 1.0 log10 decrease at 2-8 weeks and no detectable virus (<50 copies/mL) at 4-6 months after treatment initiation. Failure of therapy at 4-6 months might be ascribed to nonadherence, inadequate potency of drugs or suboptimal levels of antiretroviral agents, viral resistance, and other factors that are poorly understood. Patients whose therapy fails in spite of a high level of adherence to the regimen should have their regimen changed; this change should be guided by a thorough drug treatment history and the results of drug-resistance testing. Because of limitations in the available alternative antiretroviral regimens that have documented efficacy, optimal changes in therapy might be difficult to achieve for patients in whom the preferred regimen has failed. These decisions are further confounded by problems with adherence, toxicity, and resistance. For certain patients, participating in a clinical trial with or without access to new drugs or using a regimen that might not achieve complete suppression of viral replicatioing a regimen that might not achieve complete suppression of viral replication might be preferable. Because concepts regarding HIV management are evolving rapidly, readers should check regularly for additional information and updates at the HIV/AIDS Treatment Information Service website ( http://www.hivatis.org ).

This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendations on screening for type 2 diabetes in adults and updates the 1996 recommendations on this topic. The complete USPSTF recommendation and rationale statement on this topic, which includes a brief review of the supporting evidence, is available through the USPSTF Web site ( http://www.preventiveservices.ahrq.gov ) and the National Guideline Clearinghouse ( http://www.guideline.gov ) and in print through the Agency for Healthcare Research and Quality (AHRQ) Publications Clearinghouse (call 800-358-9295 or e-mail mailto:ahrqpubs@ahrq.gov ). The complete information on which this statement is based, including evidence tables and references, is available in the accompanying article in this issue and in the summary of the evidence and systematic evidence review on this topic on the Web sites already mentioned. The summary of the evidence is also available in print through the AHRQ Publications Clearinghouse.

This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations for use of hormone replacement therapy for the primary prevention of chronic conditions in postmenopausal women and updates the 1996 USPSTF recommendations on this topic. The complete information on which this statement is based, including evidence tables and references, is available through the USPSTF Web site (http://www.preventiveservices.ahrq.gov) and through the National Guideline Clearinghouse (http://www.guideline.gov) The USPSTF reviewed the evidence on the use of postmenopausal hormone replacement therapy and the following outcomes: cardiovascular disease, including CHD and stroke; osteoporosis and fractures; thromboembolism; dementia and cognitive function; breast, colon, ovarian, and endometrial cancer; and cholecystitis. The USPSTF also reviewed evidence of the effects of hormone replacement therapy on phytoestrogens and osteoporosis and cardiovascular disease. The use of hormone replacement therapy for relieving active symptoms of menopause, such as hot flashes, urogenital symptoms, and mood and sleep disturbances, among others, is outside the scope of these USPSTF recommendations, and literature on this topic was not reviewed. Sources for estimates of benefits and harms cited in this Recommendation statement are described in the summary of the evidence available from the Agency for Healthcare Research and Quality.

Sexually transmitted diseases (STDs) constitute an epidemic of tremendous magnitude, with an estimated 15 million persons in the United States acquiring a new STD each year. Effective clinical management of STDs is a strategic common element in efforts to prevent HIV infection and to improve reproductive and sexual health. Sexually transmitted diseases may result in severe, long-term, costly complications, including facilitation of HIV infection, tubal infertility, adverse outcomes of pregnancy, and cervical and other types of anogenital cancer. The publication of national guidelines for the management of STDs, by the U.S. Centers for Disease Control and Prevention (CDC), has been a key component of federal initiatives to improve the health of the U.S. population by preventing and controlling STDs and their sequelae. This paper presents new recommendations from the 2002 CDC Guidelines for the Treatment of Sexually Transmitted Diseases in the context of current disease trends and public health.

This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on screening for colorectal cancer and the supporting scientific evidence and updates the 1995 recommendations contained in the Guide to Clinical Preventive Services, 2nd edition. At that time, the USPSTF recommended screening for colorectal cancer with annual fecal occult blood testing, periodic sigmoidoscopy, or the combination of fecal occult blood testing and sigmoidoscopy but concluded that the evidence was insufficient to recommend for or against colonoscopy or barium enema. The complete USPSTF recommendation and rationale statement on this topic, which includes a brief review of the supporting evidence, is available through the USPSTF Web site (http://www.preventiveservices.ahrq.gov), the National Guideline Clearinghouse (http://www.guideline.gov), and in print through the Agency for Healthcare Research and Quality Publications Clearinghouse (telephone, 800-358-9295; e-mail, ahrqpubs@ahrq.gov). The complete information on which this statement is based, including tables and references, is available in the accompanying article in this issue and in the summary of the evidence and systematic evidence review on the Web sites already mentioned.

This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendations for screening for depression and the supporting scientific evidence and updates the 1996 USPSTF recommendations on this topic. At that time, the USPSTF concluded that there was insufficient evidence to recommend for or against routine use of standardized questionnaires to screen for depression in primary care patients. The complete information on which the current statement is based, including evidence tables and references, is available in the accompanying article in this issue and in the systematic evidence review on this topic, which can be obtained through the USPSTF Web site (http://www.ahrq.gov/clinic/uspstfix.htm) and in print through the Agency for Healthcare Research and Quality Publications Clearinghouse (800-358-9295).

The Hematology Disease Site Group of the Cancer Care Ontario Practice Guidelines Initiative has systematically reviewed the published literature and, through a consensus process, developed an evidence-based practice guideline assessing the role of stem-cell transplantation in patients with multiple myeloma. The conclusions were validated by solicited feedback from 221 practitioners across Ontario, Canada. The guideline comprises six recommendations: 1) Autologous transplantation is recommended for patients with stage II or III myeloma and good performance status. Evidence of benefit is strongest for patients who are younger than 55 years of age and have a serum creatinine level less than 150 micromol/L (<1.7 mg/dL). Physicians must use clinical judgment in recommending transplantation to other patients. 2) Allogeneic transplantation is not recommended as routine therapy. 3) Patients potentially eligible for transplantation should be referred for assessment early after diagnosis and should not be extensively exposed to alkylating agents before collection of stem cells. 4) Autologous peripheral blood stem cells should be harvested early in the patient's treatment course. The best available data suggest that transplantation is most advantageous when performed as part of initial therapy. 5) The comparative data addressing the specifics of the transplantation process are insufficient to allow definitive recommendations. In the absence of such data, a single transplant with high-dose melphalan, with or without total-body irradiation, is suggested for patients undergoing transplantation outside a clinical trial. 6) At this time, no conclusions can be reached about the role of interferon therapy after transplantation.