SEPTEMBER 2000 VOLUME 67 • NUMBER 9 • I S S N 0891-1150
T A B L E OF C O N T E N T S
D E D I C A T E D T O L I F E L O N G L E A R N I N G
AND T JNIC J Ö U R N A I P F
M E D I C I N E FROM THE EDITOR
Is CME test useful? 608 Do you have any suggestions? We hope to
hear from you.
J .D. C L 0 U G H
1-MINUTE CONSULT
Brief answers to specific clinical questions
What do you recommend for a patient 610 wi th a Pap smear
indicating atypical cells? The finding of atypical squamous cells
of undetermined significance ( A S C U S ) should prompt a test for
human papillomavirus.
A . W . K E N N E D Y
• What tests are necessary to diagnose Alzheimer disease? For
most patients with dementia, a clinical diagnosis is adequate.
R.J. L E D E R M A N
MEDICAL G R A N D ROUNDS
615
Heparin-induced thrombocytopenia: How to manage it, how to avoid
it What to do when heparin paradoxically causes the very problem it
is given to prevent.
E. C A I 0 L A
REVIEWS
621
Treating acute exacerbations of chronic 625 bronchitis in the
face of antibiotic resistance With bacterial resistance on the
rise, selecting the right antibiotic is crucial.
S.G. A D A M S AND A . A N Z U E T O
Vaginitis: Finding the cause 634 prevents t reatment failure To
diagnose and manage vaginitis, there is no substitute for
performing a physical and microscopic examination.
A . C L E V E L A N D
CONTINUED ON PAGE 607
JOHN D. CLOUGH, MD Editor-in-Chief
BRIAN F. MANDELL, MD, PHD Deputy Editor
LINDA K . H ENGSTLER Editor and Publisher
PHILLIP E. CANUTO Executive Editor
RAY BORAZANIAN Managing Editor
DAVIDA. HUDDLESTON Manuscript Editor
JESSICA ANCKER, ELS Editorial Services
BRUCE W. MARICH Production Manager
AMY SLUG6 MOORE Patient Education Editor
MARY BETH GLAUSER Patient Education Writer
JOHN E. PRESSELLO Art Director
ROBERT J. DEMAREST Medical Art Director
NANCY HEIM, CMI Medical Illustrator
ERMA RICHARDSON Department Coordinator
LOUISA R. PASKERT Editorial Assistant
AUDRA BUTDORF Editorial Assistant/Reprints
E D I T O R I A L A D V I S O R Y B O A R D MUZAFFAR AHMAD, WD
WILMA FOWLER BERGFELD, MD EMMANUEL L. BRAVO, MD RAY W. GIFFORD, JR,
WD WILLIAM R. HART, MD ERIC A. KLEIN, MD FLOYD D. LOOP, MD DOUGLAS
S. MOODIE, MD RICHARD H. NODAR, =HD WILLIAM L. PROUDFIT, MD WILLIAM
C. SHELDON. MD ERIC J. TOPOL, MD HERBERT P. WIEDEMANN, MD
A S S O C I A T E EDITORS
ALEJANDRO C. ARROLIGA, MD DAVID BRONSON, MD BEN H. BROUHARD. MD
MARIE BUDEV, DO WILLIAM D. CAREY, WD WILLIAM A. CHILCOTE, MD BRIAN
G. DONLEY, MD GARY FRANCIS, MD KATHLEEN FRANCO-BROMSON, MD STEVEN
M. GORDON, VID BRIAN GRIFFIN, MD HITINDER GURM, MD GARY HOFFMAN, MD
BYRON J. HOOGWERF, MD MANI S. KAVURU, MD
MANDY C. LEONARD, PHARMD ANGELO A. LICATA, MD, PHD DAVID L.
LONGWORTH, MD STEPHEN MAHONEY, MD MAURIE MARKMAN, MD ATUL C. MEHTA,
MD NEIL B. MEHTA, MD FRANKLIN A. MICHOTA, MD STEVEN NISSEN, MD
ROBERT M. PALMER. MD NORMAN B. RATLIFF, MD S. SETHU K. REDDY, MD
MARK ROTH, MD DOUGLAS SEIDNER, MD CATHY A. SILA, MD FRANCK
SKOBIERANDA, MD HOLLY L. THACKER, MD JAMES THOMAS, MD DONALD G.
VIDT, MD WILLIAM S. WILKE, MD MARC WILLIAMS, MD JAMES B. YOUNG, MD
ZOBAIR YOUNOSSI, MD
C L E V E L A N D C L I N I C F O U N D A T I O N D I V I S I O
N OF E D U C A T I O N ANDREW J. FISHLEDER, MD Chairman PHILLIP R.
GARD Administrator
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SEPTEMBER 2000 COPYRIGHT© 2000 THE CLEVELAND CLINIC FOUNDATION
PRINTED IN U.S.A.
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SEPTEMBER 2000
UPCOMING FEATURES • Diastolic dysfunction:
Causes ana t r e a t m e n t
• Genetic testing for thrombosis risk: W h e n , how, w h y
• Troponin T as a marker of myocardial infarction
• GERD in t h e elderly: Special problems
• Tricyclic overdose: Still common, deadly
• Can bra in- tumor pat ients receive ant icoagulat ion?
• Helping your pat ient lose w e i g h t
• Can ant i - in f lammatory drugs help heart failure?
• VISIT OUR WEB SITE AT HTTP://WWW.CCJM.ORG
CONTINUED FROM PAGE 602
IM BOARD REVIEW
A 42-year-old woman with polyarthritis 647 What is the cause of
this patient's symptoms? A self-test on a clinical case.
R . A . H A J J - A L I AND B.F. M A N D E L L
REVIEW
Diabetic gastropathy: 659 A practical approach to a vexing
problem A stepwise approach can improve symptoms and quality of
life while providing adequate nutrition.
B. SHEN AND E.E. SOFFER
REVIEW
Osteoarthritis: No cure, 665 but many options for symptom relief
For most patients, management options consist of nonpharmacologic
and pharmacologic therapy. Disease-modifying drugs may be on the
horizon.
R.H . M C K I N N E Y AND S . M . L I N G
REVIEW
Long-term medical complications 673 of heart transplantation:
Information for the primary care physician Caring for
heart-transplant recipients is a team effort, and primary care
physicians play a key role.
M . H . Y A M A N I AND R . C . S T A R L I N G
EDITORIAL
If it ain't broke, wha t are w e trying to fix? 682 Reprocessed
devices labeled 'for single use only' A new FDA rule will enrich
the manufacturers of medical devices and saddle us with another
layer of bureaucracy. All to fix a nonexistent problem.
J.D. C L O U G H , W . M A U R E R AND D.E . N I C K E L S O
N
DEPARTMENTS
CME Credit Test 687
H T h e Cleveland Clinic Journal of Medicine is peer-reviewed
and indexed in Index Medicus.
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 9
SEPTEMBER 2000 6 0 7
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