Screening for colorectal cancer with fecal occult blood tests or sigmoidoscopy can reduce mortality rates. If occult blood testing is done, clinicians must decide how to interpret the results and plan further management. If the results are positive, a decision must be made about evaluating the colon. This report provides information that can be used to perform fecal occult blood tests, interpret the results of those tests, and plan patient management.

The use of crude marijuana for herbal medicinal applications is now being widely discussed in both the medical and lay literature. Ballot initiatives in California and Arizona have recently made crude marijuana accessible to patients under certain circumstances. As medicinal applications of pure forms of delta-9-tetrahydrocannabinol (THC) and crude marijuana are being considered, the most promising uses of any form of THC are to counteract the nausea associated with cancer chemotherapy and to stimulate appetite. We evaluated the relevant research published between 1975 and 1996 on the medical applications, physical complications, and legal precedents for the use of pure THC or crude marijuana. Our review focused on the medical use of THC derivatives for nausea associated with cancer chemotherapy, glaucoma, stimulation of appetite, and spinal cord spasticity. Despite the toxicity of THC delivered in any form, evidence supports the selective use of pure THC preparations to treat nausea associated with cancer chemotherapy and to stimulate appetite. The evidence does not support the reclassification of crude marijuana as a prescribable medicine.

Trials of drug therapy for hypertension have shown that such therapy has a clear overall benefit in preventing cardiovascular disease. Although these trials have included slightly more women than men, it is still not clear whether treatment benefit is similar for both sexes.

High-dose intravenous immune globulin (IVIg) has emerged as an important therapy for various neurologic diseases. Different interpretations of clinical trial results; the expected benefit of IVIg compared with that of alternate therapies; and issues about IVIg's safety, cost, and mechanisms of action have raised concern and uncertainty among practitioners. To clarify these areas, this paper examines the clinical, serologic, and immunologic data on more than 110 patients with various autoimmune neurologic diseases who received IVIg during the past 6 years at the National Institute of Neurological Disorders and Stroke. It also reviews work by other investigators on the efficacy, risks, benefits, and mechanisms of the action of IVIg in these diseases. In controlled clinical trials, IVIg has been effective in treating the Guillain-Barré syndrome, multifocal motor neuropathy, chronic inflammatory demyelinating polyneuropathy, and dermatomyositis. In other controlled or open-label trials and case reports, IVIg produced improvement in several patients with the Lambert-Eaton myasthenic syndrome and myasthenia gravis but had a variable, mild, or unsubstantiated benefit in some patients with inclusion-body myositis, paraproteinemic IgM demyelinating polyneuropathy, certain intractable childhood epilepsies, polymyositis, multiple sclerosis, optic neuritis, and the stiff-man syndrome. The primary adverse reaction was headache; aseptic meningitis, skin reactions, thromboembolic events, and renal tubular necrosis occurred rarely. The most relevant immunomodulatory actions of IVIg, operating alone or in combination, are inhibition of complement deposition, neutralization of cytokines, modulation of Fc-receptor-mediated phagocytosis, and down-regulation of autoantibody production. Therapy with IVIg is effective for certain autoimmune neurologic diseases, but its spectrum of efficacy has not been fully established. Additional controlled clinical trials are needed.

Physicians and other health care professionals play an important role in reducing the delay to treatment in patients who have an evolving acute myocardial infarction. A multidisciplinary working group has been convened by the National Heart Attack Alert Program (which is coordinated by the National Heart, Lung, and Blood Institute of the National Institutes of Health) to address this concern. The working group's recommendations target specific groups of patients: those who are known to have coronary heart disease, atherosclerotic disease of the aorta or peripheral arteries, or cerebrovascular disease. The risk for acute myocardial infarction or death in such patients is five to seven times greater than that in the general population. The working group recommends that these high-risk patients be clearly informed about symptoms that they might have during a coronary occlusion, steps that they should take, the importance of contacting emergency medical services, the need to report to an appropriate facility quickly, treatment options that are available if they present early, and rewards of early treatment in terms of improved quality of life. These instructions should be reviewed frequently and reinforced with appropriate written material, and patients should be encouraged to have a plan and to rehearse it periodically. Because of the important role of the bystander in increasing or decreasing delay to treatment, family members and significant others should be included in all instruction. Finally, physicians' offices and clinics should devise systems to quickly assess patients who telephone or present with symptoms of a possible acute myocardial infarction.

The term "hypercoagulability" is used to describe patients who are at increased risk for thrombosis because of inherited defects in their anticoagulant pathways or because of various predisposing causes. About one in five patients of European descent who present with venous thromboembolism have a specific genetic defect in their anticoagulant pathway. In these patients, anticoagulant prophylaxis is indicated at times of high risk, such as after surgery. Prolonged anticoagulant therapy may be required in patients with recurrent or life-threatening thromboemboli, but decisions about this are best made on an individual basis. Patients who present with arterial thrombosis usually develop their disease as a complication of atherosclerosis. However, these patients also have a form of hypercoagulability, manifested primarily by high fibrinogen levels and elevated factor VII activity. Evidence increasingly indicates that these and other hemostatic markers may help in the assessment of patients at risk for coronary heart disease.

To review recent developments in the diagnosis, clinical epidemiology, pathology, and management of atherosclerosis of the thoracic aorta, especially atherosclerosis of the thoracic aorta as a source of embolization.

To review the literature on risk stratification after acute myocardial infarction in the reperfusion era and to propose an algorithm for early and continual risk assessment.

To assess the data that support the use of coronary angiography and angioplasty after acute myocardial infarction, that identify the risks of these procedures, and that analyze their use and costs.

To evaluate the potential benefits, harms, and economic consequences of digital rectal examination and measurement of prostate-specific antigen (PSA) for the early detection of prostate cancer.

Our concepts of the pathogenesis, diagnosis, prevention, and treatment of osteoporosis are radically changing. Some changes, such as the study of genetic determinants of bone mass and turnover and the identification of local factors in pathogenesis, have just begun. The use of bone densitometry to diagnose and predict fracture risk is well developed but not yet widely applied. Measurement of bone turnover done by using biochemical markers is a promising new diagnostic method that has already proved useful in assessing a patient's response to therapy. Options for prevention and treatment have increased substantially with the Food and Drug Administration's recent approval of alendronate (a bisphosphonate) and nasal calcitonin for treatment of osteoporosis. Some are concerned that these new agents will unduly reduce the use of estrogen, which should remain the mainstay for prevention of bone loss and fractures in postmenopausal women. New therapeutic approaches are needed to treat the established disease. Our goal should be to develop inexpensive and widely applicable methods for diagnosis, prevention, and treatment to limit the enormous increase in osteoporotic fractures that has been predicted as the aging population expands worldwide.

To estimate the prevalence of clinically important prostate cancer and to evaluate the effectiveness of digital rectal examination and measurement of prostate-specific antigen (PSA) in early detection of prostate cancer.

To review clinical interventions designed to change care at the end of life.

To develop guidelines for the diagnosis and management of idiopathic thrombocytopenic purpura (ITP) and to document the extent to which those guidelines are based on either scientific evidence or opinion, the AMerican Society of Hematology established a panel composed of 13 hematologists with expertise in ITP, a clinical epidemiologist, and a practice guidelines methodologist. A comprehensive review was done of all published English-language studies that met explicit inclusion criteria and that evaluated the natural history of ITP or the effectiveness of testing and treatment options for ITP. The quality of each study was graded by two reviewers using formal methodologic rules. In subject areas for which data was inadequate, recommendations were based on opinion and were derived by using a formal screening procedure. Confidential questionnaires were used to survey the hematologists on the panel about the appropriateness of testing and treatment options in hundreds of clinical scenarios. Practice recommendations were derived from the mean appropriateness scores for each indication. Voting was kept confidential to give each panel member an equal voice and to limit biases introduced by group dynamics. The recommendations were peer reviewed by eight outside experts. This report focuses on data and on recommendations for adults with ITP. Little high-quality scientific evidence with which to assess the efficacy of diagnostic tests and treatments for ITP is available. The opinion of the panel was that most diagnostic tests are unnecessary in the routine work-ups of patients suspected of having ITP and that ITP accompanied by severe bleeding requires treatment with glucocorticoids, intravenous immunoglobin, and other measures. However, treatment and hospitalization is often unnecessary when patients have only mild or moderate thrombocytopenia or minimal bleeding. Special therapeutic measures are sometimes indicated in pregnant women with ITP.

Adult chronic immune thrombocytopenic purpura (ITP) is a common hematologic disorder; about 14,000 to 16,000 new cases occur each year in the United States. Initial treatment with corticosteroids and splenectomy results in normal or "safe" platelet counts in more than 70% of patients. Treatment of patients refractory to these two treatments is difficult. This paper describes a structured approach to therapy that is based on a literature review and personal experience, including experience with treatment of chronic ITP in special situations (such as emergent bleeding, pregnancy, and central nervous system bleeding). Treatment of most patients with chronic ITP is fairly straightforward, but management of patients refractory to corticosteroids and splenectomy can be difficult. Large, randomized studies are clearly needed to better evaluate the many types of treatment that are recommended for refractory patients.

To review the pathogenic mechanism that lead to the poor prognosis of diabetic patients after myocardial infarction and to determine the efficacy of current interventions for myocardial infarction in these patients.