2-20 REFERENCE ARTICLES
I believe a collection of good, up-to-date narrative review articles published in the flagship journals can be primary-care physicians’ best source of "Evidence-based Medicine". They are well edited, peer reviewed, condensed, updated periodically, and contain clinical relevant information. It is not difficult to assemble a collection for ready reference. RTJ

HYPOTHYROIDISM
Symptoms and signs; diagnosis; management
The consensus opinion is that the goal for most patients on T4 replacement is to return the thyrotropin concentration to the lower part of the reference range. In this setting, free or total T4 concentrations will be at the upper limit of the reference range or slightly elevated. LANCET February 8, 1997; 349: 413-17

HYPERTHYROIDISM
Etiology; clinical features; pathophysiology; diagnosis; and management.
LANCET February 1, 1997; 349: 335-42 Review article from Univ. Of Wales College of Medicine Cardiff

WITHDRAWING INTENSIVE LIFE-SUSTAINING TREATMENT
Recommendations for compassionate clinical management
Despite an ethical and legal consensus regarding the right of patients or their surrogates to refuse life-prolonging therapy, surveys show that dying patients in hospitals in the United States frequently receive unwanted interventions.
This article addresses two essential aspects of good clinical care for dying patients: 1) Technical issues in compassionate withdrawal of life-prolonging therapy, and 2) Emotional support for patients, families, and staff during the process. It specifically addresses withdrawal of mechanical ventilation, dialysis, and artificial nutrition and hydration. NEJM February 27, 1997; 336: 652-57 "Sounding Board", commentary, first author from Michigan State University, East Lansing

THE MANAGEMENT OF PAGETS DISEASE OF BONE
With new bisphosphonate drugs, the suppression of the disease is now obtainable.
NEJM February 20, 1997; 336: 558-66 Review article from Hospital Edouard Herriot, Lyons, France

THE DIAGNOSIS OF PULMONARY EMBOLISM
Recent studies have improved interpretation of a lung scan and understanding of the natural course of what might be called non-diagnostic (lung) scan disease. It describes ways of diagnosing pulmonary embolism (PE) without resort to pulmonary angiography. (Pulmonary angiography is not generally available.) The decision to treat suspected PE in most cases has to be clinical. As a result PE is probably under treated.
The article reviews: 1) the PIOPED study (JAMA 1990; 263: 2753-59) "Value of Ventilation/Perfusion Scan In Acute Pulmonary Embolism", 2) serial non-invasive investigation of leg veins; 3) management options for suspected PE, and 4) criteria for interpreting lung scans. BMJ February 8, 1997; 314: 425-29 Review article from Southern General Hospital, Glasgow, UK

MACROCYTIC ANEMIAS
Etiology, diagnosis, and treatment. BMJ February 8, 1997; 314: 430-33 Review article from the Royal Free Hospital, London

IRON DEFICIENCY ANAEMIA
Iron metabolism, clinical features, laboratory investigations, management. BMJ February 1, 1997; 314: 360-63 Review article, first author from Southampton University Hospitals, UK

THE HEREDITARY ANAEMIAS
Sickling disorders, thalassemias, red cell enzyme defects. BMJ February 15, 1997; 314: 492-96 Clinical review from University of Oxford, Joan Radcliffe Hospital, Oxford, UK

2-21 RECOMMENDED READING ON BEDSIDE TEACHING
HYPERTENSION DETECTION AND FOLLOW-UP PROGRAM — 17 YEARS ON

2-21 RECOMMENDED READING
ON BEDSIDE TEACHING

"Actual teaching at the bedside during attending rounds with emphasis on history taking and physical diagnosis, has declined from an incidence of 75% in the 1960s to an incidence of less than 16% today."
"And if we are to become effective bedside teachers, as were our mentors, we will need to sharpen our own physical diagnostic skills. We will need to learn how to be gentle with students and house staff, how to better communicate with patients, and how to teach ethics and professionalism with the patient at hand." Annals Int. Med. February 1, 1997; 126: 217-20 Essay from a physician in Bridgeton , Maine

2-21 THE HYPERTENSION DETECTION AND FOLLOW-UP PROGRAM —17 YEARS ON
The HDFP was published in 1979. This landmark study found that, overall, lowering diastolic BP by 5-6 mm Hg for 5 years reduced cardiovascular deaths by 20%, fatal stroke by 45%, and nonfatal myocardial infarction by 12%.
However, there were great differences in absolute risk in subgroups. The benefit of drug therapy for hypertension is heavily influenced by the initial absolute cardiovascular risk. Whites have less risk than blacks; young less risk than old; those with lower BPs have less risk than those with higher levels. Those with target damage have the highest risk.
In those age 30-49, step care of 600 subjects for 5 years prevented one death from stroke, one non-fatal stroke, and the development of left ventricular hypertrophy in 2. The number needed to treat in this age group is high.
The author of this article adds 9 words to the conclusion of the original report: systematic management of hypertension reduces mortality in people with high blood pressure, including these with mild hypertension who have cardiovascular risk sufficiently high to warrant (drug) treatment.
Would fully informed subjects on average choose to take treatment for 5 years for a 1 in 300 chance of preventing a cardiovascular event? We do not know and we should ask them.

JAMA January 8, 1997; 277: 167-70 "Landmark Perspective" from Royal Hallamshire Hospital, Sheffield, England
The original 1997 article is reprinted on pages 157-166.

Comment:
Again, this concerns drug therapy. Life-style therapy should be prescribed in all patients with hypertension, even the mildest. The benefit/harm-cost ratio of life-style therapy is high.
At age 40, I would be willing to take low-dose diuretic therapy even though the risk of an adverse event is low. This is because early continued treatment will likely prevent development of more severe hypertension at age 50-60, and lessen the likelihood of later target organ damage. RTJ

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