In the United States, chronic hepatitis C virus (HCV) infection affects an estimated 3 million persons, most younger than 50 years of age. It is one of the leading causes of chronic liver disease morbidity and mortality and the most common indication for liver transplantation. Effective treatment can eradicate the virus and eliminate or reduce liver inflammation and fibrosis, and counseling and immunization can modify or prevent the adverse effect of cofactors (for example, alcohol consumption or co-infections) on disease progression. However, controversy surrounds the need to routinely identify asymptomatic HCV-infected persons. Because no data currently demonstrate that treatment or other interventions will reduce future cases of HCV-related chronic disease and deaths, the U.S. Preventive Services Task Force found insufficient evidence to recommend for or against routine screening for HCV infection in adults at high risk. Chronic hepatitis C would require many years of follow-up to determine the incidence of complication after treatment of or other interventions in asymptomatic persons. It seems inappropriate to wait several decades to measure the impact of early identification of this viral infection when current data support a positive therapeutic effect that points to long-term benefits. In addition, treatment and other interventions must be provided before cirrhosis or liver failure occurs. Therefore, medical and public health professionals should continue the practice of screening persons for risk factors; offering testing to those at increased risk for HCV infection; and providing infected persons with appropriate counseling, medical evaluation, and treatment.

The role of angiotensin-receptor blockers (ARBs) in treating patients with chronic heart failure and high-risk acute myocardial infarction (MI) has been controversial, and recent clinical trials provide more information on this topic.

Hypertension occurs more frequently and is generally more severe in black persons than in white persons, leading to excess morbidity and mortality.

In 1999, the American College of Physicians (ACP), then the American College of Physicians-American Society of Internal Medicine, and the American College of Cardiology/American Heart Association (ACC/AHA) developed joint guidelines on the management of patients with chronic stable angina. The ACC/AHA then published an updated guideline in 2002, which ACP recognized as a scientifically valid review of the evidence and background paper. This ACP guideline summarizes the recommendations of the 2002 ACC/AHA updated guideline and underscores the recommendations most likely to be important to physicians seeing patients in the primary care setting. This guideline is the second of 2 that provide guidance on the management of patients with chronic stable angina. This document covers treatment and follow-up of symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months. Sections addressing asymptomatic patients are also included. Asymptomatic refers to patients with known or suspected coronary disease based on a history or electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests. A previous guideline covered diagnosis and risk stratification for symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months and asymptomatic patients with known or suspected coronary disease based on a history or electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests.

Nearly 1500 malaria cases occur each year in the United States; approximately 60% are among U.S. travelers. Despite the availability of sophisticated medical care, malaria-related deaths continue to occur. The authors reviewed all 185 fatal cases between 1963 and 2001 that were reported to the National Malaria Surveillance System: 123 (66.5%) occurred among U.S. travelers, and of these, 114 (92.7%) were attributed to Plasmodium falciparum. Failure to take or adhere to recommended chemoprophylaxis, to promptly seek medical care for post-travel illness, and to promptly diagnose and treat suspected malaria all contributed to fatal outcomes. Health care providers need to take a travel history, obtain a blood film for suspected malaria, and use the 24-hour malaria management advice available through the Centers for Disease Control and Prevention (CDC) Malaria Hotline (770-488-7788) or the CDC Malaria Web site (http://www.cdc.gov/Malaria). Hospitals must maintain intravenous quinidine gluconate on formulary because it is the only drug available to treat severe malaria in the United States.

Although clinicians commonly use computed tomography or ultrasonography to diagnose acute appendicitis, the accuracy of these imaging tests remains unclear.

In persons with diabetes, chronic hyperglycemia (assessed by glycosylated hemoglobin level) is related to the development of microvascular disease; however, the relation of glycosylated hemoglobin to macrovascular disease is less clear.

Even with optimal pharmacotherapy, symptomatic heart failure is associated with substantial morbidity and mortality.

Ventilator-associated pneumonia (VAP) is an important patient safety issue in critically ill patients.

According to data from randomized, controlled trials, primary percutaneous coronary intervention (PCI) is the treatment of choice for ST-segment elevation myocardial infarction (MI). In these trials, 1 life was saved and 2 other life-threatening complications, including stroke and reinfarction, were prevented for every 50 patients with ST-segment elevation MI treated with primary PCI rather than thrombolytic therapy. Only 1 major bleeding episode occurred. How can these superior results be realized outside the context of randomized trials? We anticipate 4 obstacles to instituting primary PCI as the universal treatment of ST-segment elevation MI: 1) lack of timely availability, 2) technical expertise of center and operator, 3) the need to address patient subgroups that are not studied in randomized trials, and 4) comparisons of primary PCI to newer pharmacologic regimens. We propose 3 strategies to increase the availability of this procedure: 1) perform primary PCI in qualified community hospitals without surgical back-up; 2) transfer patients from community hospitals without primary PCI capability to hospitals with primary PCI capability; and 3) develop a universal system in which ambulances directly transfer patients to a regional primary PCI center, not necessarily to the closest hospital, similar to the system used for trauma patients. We contend that, in light of the superior clinical outcomes seen with primary PCI for treating ST-segment elevation MI, this procedure should be available to all patients with ST-segment elevation MI and efforts should be made to institute these measures.

Primary angioplasty is increasingly being advocated as the preferred approach for treating acute ST-segment elevation myocardial infarction regardless of whether interinstitutional transfer is required. This review critically analyzes the evidence comparing primary angioplasty with thrombolytic therapy and concludes that reasonable health care professionals may still find considerable uncertainty about the superiority of primary angioplasty for all situations. The magnitude of benefit for primary angioplasty over thrombolysis is probably less than 1 to 2 lives saved/100 patients treated and largely depends on the choice of thrombolytic agent, time to treatment, place of treatment, and adjunctive therapy. There is little evidence that systematically transferring patients for primary angioplasty in routine practice will provide any health benefits over thrombolysis. Consequently, it may be most useful to view these treatments as complementary rather than competitive. Thrombolysis remains a clinically and economically attractive option for the treatment of acute myocardial infarction that does not require the radical restructuring of our health care systems.

Disparities clearly exist in the health care of racial and ethnic minorities. This position paper of the American College of Physicians (ACP) provides ample evidence illustrating that minorities do not always receive the same quality of health care, do not have the same access to health care, are less represented in the health professions, and have poorer overall health status than nonminorities. The ACP finds this to be a major problem in our nation's health system that must be addressed. The ACP is dedicated to working toward eliminating all disparities in health care. This position paper sets forth specific positions for reducing these disparities and will be the foundation for public policy advocacy by ACP for eliminating racial and ethnic disparities in health care.

Apolipoprotein E (apoE) genotypes play critical roles in lipid metabolism and are believed to influence risk for coronary heart disease (CHD). Despite many population studies, however, the impact of apoE polymorphism on risk for CHD remains uncertain.

In 1999, the American College of Physicians (ACP), then the American College of Physicians-American Society of Internal Medicine, and the American College of Cardiology/American Heart Association (ACC/AHA) developed joint guidelines on the management of patients with chronic stable angina. The ACC/AHA then published an updated guideline in 2002, which the ACP recognized as a scientifically valid review of the evidence and background paper. This ACP guideline summarizes the recommendations of the 2002 ACC/AHA updated guideline and underscores the recommendations most likely to be important to physicians seeing patients in the primary care setting. This guideline is the first of 2 that will provide guidance on the management of patients with chronic stable angina. This document will cover diagnosis and risk stratification for symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months. Sections addressing asymptomatic patients are also included. Asymptomatic refers to patients with known or suspected coronary disease based on history or on electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests. A future guideline will cover pharmacologic therapy and follow-up.

Previous meta-analyses demonstrated that high-dose glucocorticoids were not beneficial in sepsis. Recently, lower-dose glucocorticoids have been studied.

The findings of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) have generated worldwide reaction from clinicians and researchers, including a recent commentary in this journal. Such response was expected for a trial of ALLHAT's size and scope, especially since its results challenged some widely held beliefs. This paper reviews key aspects of the ALLHAT design, analyses, findings, and conclusions to provide a perspective on the commentary about the trial's results and implications for clinical practice. Several of the most frequent comments regarding the study's results are addressed, particularly with respect to heart failure and diabetes outcomes. Responses to these comments reinforce the investigators' original conclusion that thiazide-type diuretics should remain the preferred first-step drug class for treating hypertension and should generally be a part of any multidrug regimen.