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Resolutions 2004.

At the start of the new year, we review recent items that merit emphasis for incorporation into daily practice and survey trends that bear watching in the coming months. Here are some resolutions for 2004:

Develop effective care for hepatitis C. This prevalent condition lends itself to antiviral therapy, especially for serotypes 2 and 3 Costeffective use of pegylated interferon in combination with ribavirin requires discontinuation after 12 weeks if viral loads do not decrease by 2 log from baseline. Given an appropriate therapeutic response at 12 weeks, patients infect ed with serotypes 2 and 3 should receive 24 weeks of therapy; those afflicted with the more resistant serotype 1 should get a total of 48 weeks of antiviral medication.

Beware of screening mythology. The following tests have little published evidence to support their use:

* Alpha fetoprotein to screen for hepatocellular carcinoma.

* Cardiac stress testing and electron-beam coronary CT scans for individuals who are asymptomatic.

* Chest x-rays and sputum cytology to screen for lung cancer, even in a high-risk population.

Review guidelines for colorectal cancer screening. Screen average risk adults over age 50 years with annual fecal occult blood testing, sigmoidoscopy or air contrasted barium enema every 5 years, or colonoscopy every 10 years. These proven methodologies remain under utilized. Virtual colonoscopy using CT scanning with computerized reconstruction and stool DNA detection tests have yet to meet evidentiary standards for use in routine screening, but they may be useful in the future.

Understand complication rates for bariatric surgery. Surgical intervention can produce dramatic, sustainable weight loss in the morbidly obese, but with a substantial risk tot morbidity: About one-third of patients develop gallstones within 6 months after surgery. 5%-15% suffer stomal stenosis that presents with nausea and vomiting, and 5%-15% present with marginal ulcers. Iron, calcium, folate, and vitamin [B.sub.12], de ficiencies are common. Substantial weight loss can restore dormant menstrual cycles and place a patient at risk for unintended pregnancy

Support patients and colleagues enduring divorce. Halt of all marriages and 60% of second marriages end in divorce. One-quarter of children in the United States live with their single mother and less than 60% live with both biulogic parents. By supporting parents during the lengthy and stressful process of divorce. physicians could enhance parenting skills, which have greater impact on the mental health and welfare of affected children than custody arrangements.

Think about the metabolic syndrome. Patients with fasting glucose over 110 mg/dL, fasting triglycerides over 150 mg/dL, abdominal obesity, blood pressure over 135/85 mm Hg, and low HDL cholesterol levels need increased attention for their elevated cardinvascular risk.

Reconsider Barrett's esophagus. After years of confusion in the medical literature, there are now defined criteria for diagnosing Barrett's esophagus, a condition associated with chronic reflux esophagitis that also places the patient at increased risk for esophageal carcinoma. Patients with Barrett's deserve periodic surveillance of esophageal histology to detect early metaplasia that could benefit from aggressive intervention.

Maintain skepticism on supplements. Despite widespread use of supplements, there is little supporting evidence in the following clinical circumstances:

* Hormone therapy, vitamin C, and vitamin E do not reduce cardiovascular risk.

* Well-designed clinical trials have tailed to show that dietary supplements have an effect on obstructive symptoms in benign prostatic hypertrophy.

Do not dismiss electronic medical records for your clinical setting. Only a minority of physicians have EMRs in their offices. Although implementation of such systems changes clinical dynamics, they offer many advantages that promote patient safety and quality improvement. We estimate that EMRs may be wide spread by 2010 and become essential for reimbursement incentives, particularly payment for performance.

Monitor office-based performance measurement. In the next 5 years, measurement of your compliance with national clinical standards in the office setting will grow in importance and sponsorship. Insurers, government programs, and even board recertification requirements will incorporate national standards into required, ongoing clinical self-assessment. Good long-term planning will prepare your office to integrate this trend into daily practice. with less future shock down the road

We hope that you and your office staff have returned from the holiday season reenergized for the year ahead. As we enter our seventh year of the Effective Physician, we will continue to offer a concise service that highlights core aspects of guidelines that may well translate into future performance measures of your clinical practice. Please send suggestions and feedback to us and make use of the archive of past columns at Best wishes for the new year.

DR. WILLIAM E. GOLDEN is professor of medicine and public health and DR. ROBERT H. HOPKINS is associate director of the medicine/pediatrics residency program at the University of Arkansas. Write to Dr. Hopkins and Dr. Golden at our editorial offices or
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Title Annotation:The Effective Physician
Author:Golden, William E.; Hopkins, Robert H.
Publication:Internal Medicine News
Date:Jan 1, 2004
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