Multivitamin and mineral supplements are the most commonly used dietary supplements in the United States.

The emergence of multiple insulin products has provided new opportunities to achieve diabetes control. However, the number of options has raised concerns about the optimal choices of products.

Albuminuria is an independent risk factor for cardiovascular and renal disease with limited therapeutic options. Data on the effects of statins on albuminuria are conflicting.

Conflicting reports have caused controversy on whether cysticidal drugs modify the natural course of neurocysticercosis.

Some experts propose C-reactive protein (CRP) as a screening tool for prediction of cardiovascular disease (CVD). Many epidemiologic studies show positive associations between elevated CRP levels and incident CVD. Assessment of the value of new prognostic tests, however, must rely on understanding of test characteristics rather than on associations measured by relative risks. In the case of CRP, test characteristics must be judged in the context of currently available CVD risk prediction algorithms. In this review of literature published before January 2006, the authors describe what is known about the additional utility of CRP in risk prediction. They find no definitive evidence that, for most individuals, CRP adds substantial predictive value above that provided by risk estimation using traditional risk factors for CVD. Use of CRP may add to risk estimation in a limited subset of individuals who are at intermediate predicted risk according to the Framingham risk score. The authors propose that many questions still must be addressed before CRP is incorporated into risk prediction algorithms and before universal screening with CRP can be recommended.

The threat of an H5N1 influenza virus (avian flu) pandemic is substantial. The success of the current U.S. influenza pandemic response plan depends on effective coordination among state and local public health authorities and individual health care providers. This article is a summary of a public policy paper developed by the American College of Physicians to address issues in the U.S. Department of Health and Human Services Pandemic Influenza Plan that involve physicians. The College's positions call for the following: 1) development of local public health task forces that include physicians representing all specialties and practice settings; 2) physician access to 2-way communication with public health authorities and to information technology tools for diagnosis and syndrome surveillance; 3) clear identification and authorization of agencies to process licensing and registration of volunteer physicians; 4) clear guidelines for overriding standard procedures for confidentiality and consent in the interest of the public's health; 5) clear and fair infection control measures that do not create barriers to care; 6) analysis of and solutions to current problems with seasonal influenza vaccination programs as a way of developing a maximally efficient pandemic flu vaccine program; 7) federal funding to provide pandemic flu vaccine for the entire U.S. population and antiviral drugs for 25% of the population; and 8) planning for health care in alternative, nonhospital settings to prevent a surge in demand for hospital care that exceeds supply. *This paper is an abridged version of a full-text position paper (available at http://www.acponline.org/college/pressroom/as06/pandemic_policy.pdf) written by Laura Barnitz, BJ, MA, and updated and adapted for publication in Annals of Internal Medicine by Michael Berkwits, MD, MSCE. The original position paper was developed for the Health and Public Policy Committee of the American College of Physicians: Jeffrey P. Harris, MD (Chair); David L. Bronson, MD (Vice Chair); CPT Julie Ake, MD; Patricia P. Barry, MD; Molly Cooke, MD; Herbert S. Diamond, MD; Joel S. Levine, MD; Mark E. Mayer, MD; Thomas McGinn, MD; Robert M. McLean, MD; Ashley E. Starkweather; and Frederick E. Turton, MD. It was approved by the Board of Regents on 3 April 2006.

Interventional cardiologists have quickly replaced bare metal stents with intravascular drug-eluting stents for treating and preventing restenosis, largely on the basis of empirical evidence that shows profound reduction in angiographic and clinical restenosis. A critical reassessment of the published evidence, however, suggests that the putative superiority of intravascular drug-eluting stents is founded on questionable premises, including 1) overestimation of restenosis benefit, 2) underestimation of the risk for stent thrombosis, 3) overreliance on "soft" rather than "hard" outcomes (need for repeated revascularization vs. death or myocardial infarction), and 4) the attendant overestimation of cost-effectiveness. Because the long-term incremental risks, benefits, and costs of drug-eluting stents have not yet been optimally evaluated in a broad spectrum of patient and lesion cohorts, the rational role of these devices in clinical management warrants reappraisal.

There is increased interest in quantitative ultrasound for osteoporosis screening because it predicts fracture risk, is portable, and is relatively inexpensive. However, there is no consensus regarding its accuracy for identifying patients with osteoporosis.

Long-acting beta-agonists may increase the risk for fatal and nonfatal asthma exacerbations.

The prevalence of chronic hepatitis C virus (HCV) infection in prisons ranges from 12% to 31%. There are generally accepted--albeit still evolving--guidelines for identification and treatment of hepatitis C in the community. However, there is less agreement among health professionals caring for prisoners about best practices for identification, medical management, and treatment of hepatitis C. Inmates often lack health care before incarceration. In prisons, infected persons could be identified and the management of infection initiated; however, the high prevalence of HCV infection among prisoners would impose a disproportionate cost for hepatitis C care on the correctional system. The optimal solution is for prison and public health systems in the United States to jointly provide targeted HCV testing and standard-of-care hepatitis C medical management, treatment, and prevention programs to prison inmate populations. The authors report on a January 2003 meeting of experts in prison health, public health, hepatology, and infectious diseases and explore the clinical care, prevention, and collaboration needed to provide hepatitis C management in prisoners.

Osteonecrosis of the jaws is a recently described adverse side effect of bisphosphonate therapy. Patients with multiple myeloma and metastatic carcinoma to the skeleton who are receiving intravenous, nitrogen-containing bisphosphonates are at greatest risk for osteonecrosis of the jaws; these patients represent 94% of published cases. The mandible is more commonly affected than the maxilla (2:1 ratio), and 60% of cases are preceded by a dental surgical procedure. Oversuppression of bone turnover is probably the primary mechanism for the development of this condition, although there may be contributing comorbid factors. All sites of potential jaw infection should be eliminated before bisphosphonate therapy is initiated in these patients to reduce the necessity of subsequent dentoalveolar surgery. Conservative débridement of necrotic bone, pain control, infection management, use of antimicrobial oral rinses, and withdrawal of bisphosphonates are preferable to aggressive surgical measures for treating this condition. The degree of risk for osteonecrosis in patients taking oral bisphosphonates, such as alendronate, for osteoporosis is uncertain and warrants careful monitoring.

Experts consider health information technology key to improving efficiency and quality of health care.

Dose adjustment or laboratory monitoring of low-molecular-weight heparin (LMWH) is commonly recommended for patients with severe renal insufficiency (creatinine clearance < or =30 mL/min), but the basis for this recommendation is unclear.

Postoperative pulmonary complications are as frequent and clinically important as cardiac complications in terms of morbidity, mortality, and length of stay. However, there has been much less research and no previous systematic reviews of the evidence of interventions to prevent pulmonary complications.

The importance of clinical risk factors for postoperative pulmonary complications and the value of preoperative testing to stratify risk are the subject of debate.

Postoperative pulmonary complications play an important role in the risk for patients undergoing noncardiothoracic surgery. Postoperative pulmonary complications are as prevalent as cardiac complications and contribute similarly to morbidity, mortality, and length of stay. Pulmonary complications may even be more likely than cardiac complications to predict long-term mortality after surgery. The purpose of this guideline is to provide guidance to clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery. It also evaluates strategies to reduce the perioperative pulmonary risk and focuses on atelectasis, pneumonia, and respiratory failure. The target audience for this guideline is general internists or other clinicians involved in perioperative management of surgical patients. The target patient population is all adult persons undergoing noncardiothoracic surgery.

Obesity is a major risk factor for heart disease. In the face of obesity's growing prevalence, it is important for physicians to be aware of emerging research of novel mechanisms through which adiposity adversely affects the heart. Conventional wisdom suggests that either hemodynamic (that is, increased cardiac output and hypertension) or metabolic (that is, dyslipidemic) derangements associated with obesity may predispose individuals to coronary artery disease and heart failure. The purpose of this review is to highlight a novel mechanism for heart disease in obesity whereby excessive lipid accumulation within the myocardium is directly cardiotoxic and causes left ventricular remodeling and dilated cardiomyopathy. Studies in animal models of obesity reveal that intracellular accumulation of triglyceride renders organs dysfunctional, which leads to several well-recognized clinical syndromes related to obesity (including type 2 diabetes). In these rodent models, excessive lipid accumulation in the myocardium causes left ventricular hypertrophy and nonischemic, dilated cardiomyopathy. Novel magnetic resonance spectroscopy techniques are now available to quantify intracellular lipid content in the myocardium and various other human tissues, which has made it possible to translate these studies into a clinical setting. By using this technology, we have recently begun to study the role of myocardial steatosis in the development of obesity-specific cardiomyopathy in humans. Recent studies in healthy individuals and patients with heart failure reveal that myocardial lipid content increases with the degree of adiposity and may contribute to the adverse structural and functional cardiac adaptations seen in obese persons. These studies parallel the observations in obese animals and provide evidence that myocardial lipid content may be a biomarker and putative therapeutic target for cardiac disease in obese patients.