Physicians, hospitals, and other health care facilities will assume the responsibility for aiding individuals injured by a terrorist act involving radioactive material. Scenarios have been developed for such acts that include a range of exposures resulting in few to many casualties. This consensus document was developed by the Strategic National Stockpile Radiation Working Group to provide a framework for physicians in internal medicine and the medical subspecialties to evaluate and manage large-scale radiation injuries. Individual radiation dose is assessed by determining the time to onset and severity of nausea and vomiting, decline in absolute lymphocyte count over several hours or days after exposure, and appearance of chromosome aberrations (including dicentrics and ring forms) in peripheral blood lymphocytes. Documentation of clinical signs and symptoms (affecting the hematopoietic, gastrointestinal, cerebrovascular, and cutaneous systems) over time is essential for triage of victims, selection of therapy, and assignment of prognosis. Recommendations based on radiation dose and physiologic response are made for treatment of the hematopoietic syndrome. Therapy includes treatment with hematopoietic cytokines; blood transfusion; and, in selected cases, stem-cell transplantation. Additional medical management based on the evolution of clinical signs and symptoms includes the use of antimicrobial agents (quinolones, antiviral therapy, and antifungal agents), antiemetic agents, and analgesic agents. Because of the strong psychological impact of a possible radiation exposure, psychosocial support will be required for those exposed, regardless of the dose, as well as for family and friends. Treatment of pregnant women must account for risk to the fetus. For terrorist or accidental events involving exposure to radioiodines, prophylaxis against malignant disease of the thyroid is also recommended, particularly for children and adolescents.

The National Diabetes Prevention and Control Program has a dynamic and evolving scientific foundation. This article describes this program and how seminal research studies provide an impetus for its public health policy and programs. The charge and challenges of integrating science into past, current, and future program designs are detailed, as are the program's accomplishments. Areas requiring new science are explored, including better research to translate new findings into clinical and public health practice and models to evaluate the effect of public health on improved outcomes. The epidemic of diabetes and its increasing burden on public health demands a better understanding of existing science and its limitations and informed public dialogue and policy responses.

Facing limited resources and increases in demand from competing programs, policymakers and health care providers seek guidance from economic studies on how to use health care resources wisely. Previous economic studies mainly focused on estimating the cost of diabetes and cost-effectiveness of different interventions. These studies found that diabetes is costly and that its cost will continue to increase; thus, more resources should be devoted to research aimed at finding effective means to prevent the disease and its complications. In addition, the cost-effectiveness of interventions varies greatly in terms of quality-adjusted life-years gained; therefore, efficient uses of resources should be an important consideration when interventions are prioritized. The need for economic studies will continue to grow because of increasing demand for limited resources from the growing number of interventions available. Future studies should be of better quality and broadened in areas of research.

Eight studies included in a recent systematic review of the efficacy of diabetes self-management education were qualitatively reexamined to determine the presence of theoretical frameworks, methods used to ensure cultural appropriateness, and the quality of the instrument. Theoretical frameworks that help to explain complex pathways that produce health outcomes were lacking; culture indices were not incorporated into diabetes self-management education; and the instruments used to measure outcomes were inadequate. We provide recommendations to improve research on diabetes self-management education in community settings through use of a contextual framework that encourages targeting multiple levels of influence--individual, family, organizational, community, and policy.

Translation research transforms currently available knowledge into useful measures for everyday clinical and public health practice. We review the progress in diabetes translation research and identify future challenges and opportunities in this field. Several promising interventions to optimize implementation of efficacious diabetes treatments are available. Many of these interventions, singly or in combination, need to be more formally tested in larger randomized or quasi-experimental practical trials using outcomes of special interest to patients (for example, patient satisfaction and quality of life) and policymakers (for example, cost and cost-effectiveness). The long-term outcomes (such as morbidity, mortality, quality of life, and costs) of strategies aimed at improving diabetes care must be assessed. Translation research also needs to incorporate ways of studying complex systems of care. The challenges and opportunities offered by translation research are tremendous.

More than 18 million Americans currently have diabetes mellitus. The economic and human cost of the disease is devastating. In the United States, diabetes is the most common cause of blindness among working-age adults, the most common cause of nontraumatic amputations and end-stage renal disease, and the sixth most common cause of death. For the cohort of Americans born in 2000, the estimated lifetime risk for diabetes is more than 1 in 3. In the next 50 years, the number of diagnosed cases of diabetes is predicted to increase by 165% in the United States, with the largest relative increases seen among African Americans, American Indians, Alaska Natives, Asian and Pacific Islanders, and Hispanic/Latino persons. Compelling scientific evidence indicates that lifestyle change prevents or delays the occurrence of type 2 diabetes in high-risk groups. This body of evidence from randomized, controlled trials conducted in 3 countries has definitively established that maintenance of modest weight loss through diet and physical activity reduces the incidence of type 2 diabetes in high-risk persons by about 40% to 60% over 3 to 4 years. The number of persons at high risk for type 2 diabetes is similar to the number of persons who have diabetes. This paper summarizes scientific evidence supporting lifestyle intervention to prevent type 2 diabetes and discusses major policy challenges to broad implementation of lifestyle intervention in the health system.

A diabetes epidemic emerged during the 20th century and continues unchecked into the 21st century. It has already taken an extraordinary toll on the U.S. population through its acute and chronic complications, disability, and premature death. Trend data suggest that the burden will continue to increase. Efforts to pre- vent or delay the complications of diabetes or, better yet, to prevent or delay the development of diabetes itself are urgently needed.

Given the threat of bioterrorism and the increasing availability of electronic data for surveillance, surveillance systems for the early detection of illnesses and syndromes potentially related to bioterrorism have proliferated.

Suicide is the 11th leading cause of death and the seventh leading cause of years of potential life lost in the United States. Although suicide is of great public health significance, its clinical management is complicated.

This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendations on screening for suicide risk and the supporting scientific evidence and updates the 1996 recommendations on this topic. 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 systematic evidence review on this topic, which is available through the USPSTF Web site (www.preventiveservices.ahrq.gov) and through the National Guideline Clearinghouse (www.guideline.gov). The complete recommendation statement and the summary of the evidence are also available from the Agency for Healthcare Research and Quality Publications Clearinghouse (telephone, 800-358-9295; e-mail, ahrqpubs@ahrq.gov).

The regular administration of beta2-agonists may be associated with the development of tolerance to their effects.

Lung cancer is the leading cause of cancer-related death in the United States and worldwide. No major professional organizations, including the U.S. Preventive Services Task Force (USPSTF), currently recommend screening for lung cancer.

This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on screening for lung cancer and the supporting scientific evidence and updates the 1996 recommendations on this topic. In 1996, the USPSTF recommended against screening for lung cancer (a grade D recommendation). The Task Force now uses an explicit process in which the balance of benefits and harms is determined exclusively by the quality and magnitude of the evidence. As a result, current letter grades are based on different criteria than those used in 1996. 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 systematic evidence review on this topic, available through the USPSTF Web site (http://www.preventiveservices.ahrq.gov) and the National Guideline Clearinghouse (http://www.guideline.gov). The complete USPSTF recommendation statement (which includes a brief review of the supporting evidence) and the summary of the evidence are also available in print through the Agency for Healthcare Research and Quality Publications Clearinghouse (telephone, 800-358-9295; e-mail, ahrqpubs@ahrq.gov).

Myocardial infarction is the leading cause of congestive heart failure and death in the industrialized world. Current therapy is limited in preventing the progression of ventricular remodeling and congestive heart failure. Recent interest has focused on stem cells, which are undifferentiated and pluripotent cells that can proliferate, potentially self-renew, and differentiate into cardiomyocytes. Myocardial regeneration with stem-cell transplantation is a possible treatment option to reverse the deleterious hemodynamic and neurohormonal effects that occur after myocardial infarction and can lead to congestive heart failure. Various preclinical animal studies show the potential to regenerate myocardium and improve perfusion to the infarct area to improve cardiac function but also suggest that stem cells may have proarrhythmic effects. Early phase I clinical studies indicate that stem-cell transplantation is feasible and may have beneficial effects on ventricular remodeling after myocardial infarction. Future randomized clinical trials will establish the magnitude of the benefit and the effects on arrhythmias after stem-cell therapy.

Cardiovascular disease is the primary complication and cause of death in patients with type 2 diabetes mellitus. Modification of cardiovascular risk factors may improve patient outcomes.

In an effort to provide internists and other primary care physicians with effective management strategies for diabetes care, the Clinical Efficacy Assessment Subcommittee (CEAS) of the American College of Physicians (ACP) decided to develop guidelines on the management of dyslipidemia, particularly hypercholesterolemia, in people with type 2 diabetes mellitus. The CEAS commissioned a systematic review of the currently available evidence on the management of lipids in type 2 diabetes mellitus. The evidence review is presented in a background paper in this issue. On the basis of this systematic review, the CEAS developed recommendations that the ACP Board of Regents then approved as policy. The target audience for this guideline is all clinicians who care for patients with type 2 diabetes. The target patient population is all persons with type 2 diabetes, including those who already have some form of microvascular complication and, of particular importance, premenopausal women. The recommendations are as follows. RECOMMENDATION 1: Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and morbidity for all patients (both men and women) with known coronary artery disease and type 2 diabetes. RECOMMENDATION 2: Statins should be used for primary prevention against macrovascular complications in patients (both men and women) with type 2 diabetes and other cardiovascular risk factors. RECOMMENDATION 3: Once lipid-lowering therapy is initiated, patients with type 2 diabetes mellitus should be taking at least moderate doses of a statin. RECOMMENDATION 4: For those patients with type 2 diabetes who are taking statins, routine monitoring of liver function tests or muscle enzymes is not recommended except in specific circumstances.

Internists care for many women who have had abortions and many who will seek abortions in the future. Each year, about 2% of all women of reproductive age have an abortion. Women having abortions tend to be young, white, unmarried, and early in pregnancy. Most abortions are done by suction curettage under local anesthesia in a freestanding clinic. However, medical abortion is growing in popularity as a nonsurgical alternative. The regimen approved by the U.S. Food and Drug Administration specifies mifepristone, 600 mg orally, followed 2 days later by misoprostol, 400 microg orally (within 49 days from last menses). Recent studies have recommended alternative approaches, such as mifepristone, 200 mg orally, followed in 1 to 3 days by misoprostol, 800 microg vaginally (up to 63 days). Medical abortion can be provided by a broader variety of physicians than can surgical abortion. The overall case-fatality rate for abortion is less than 1 death per 100,000 procedures. Infection, hemorrhage, acute hematometra, and retained tissue are among the more common complications. Referral back to the original abortion provider for management is advisable. Overall, induced abortion does not lead to late sequelae, either medical or psychiatric. Of importance, no link exists between induced abortion and later breast cancer. For physicians who are asked to help with a referral, the National Abortion Federation and Planned Parenthood Federation of America have helpful Web sites and networks of high-quality clinics. The cost of abortion (currently about 372 dollars at 10 weeks) has decreased in recent decades. Provision of ongoing contraception and encouragement of emergency contraception can reduce unintended pregnancies and the need for abortion.

Despite extensive literature, the diagnostic role of d-dimer for deep venous thrombosis (DVT) or pulmonary embolism (PE) remains unclear, reflecting multiple d-dimer assays and concerns about differing sensitivities and variability.

Coronary heart disease is the leading cause of morbidity and mortality in the United States. Exercise tolerance testing has been proposed as a means of better identifying asymptomatic patients at high risk for coronary heart disease events.