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An algorithmic approach to evaluation of dyspepsia or abdominal discomfort begins with differentiation between peptic ulcer disease and gastroesophageal reflux disease as well as recognition of alarm signs and symptoms for gastric cancer, which are indications for early endoscopy. In the absence of alarm symptoms, most patients should undergo noninvasive testing for H pylori infection with a serologic, urea breath, or stool antigen test. Factors to consider in selection of appropriate testing include reliability, specificity, sensitivity, cost, and local access and expertise. As a general rule, physicians should choose a test that has the best accuracy for the level of testing expertise available. The basic principle underlying testing for H pylori is that patients should not undergo testing unless the physician is willing to treat on the basis of a positive test result. In patients who receive treatment, confirmation of cure is important for preventing further morbidity and reducing risk of transmission of infection.

Maintaining tight glycemic control is an important issue for patients with type 2 diabetes. Empowering patients to be actively involved in the management of their diabetes can improve glycemic control through education, communication, and the use of patient-friendly insulin regimens. The primary care physician plays an important role in helping patients manage their disease by encouraging initiation of treatment with insulin analogs, which are more convenient, more predictable, and better tolerated than traditional human insulin therapies. Modern insulin delivery devices, such as insulin pens, may also help improve patient acceptance of insulin therapy.

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although frequently undiagnosed, OSA is highly prevalent and presents most often with excessive daytime sleepiness (EDS). While obesity is the major predisposing factor, patients with OSA and EDS are at increased risk of other conditions, including cardiovascular disease, type 2 diabetes, cognitive impairment, and depression. Significant consequences include morbidity and mortality from the associated conditions in addition to personal and societal consequences of cognitive impairment, such as driving and workplace accidents. Primary care physicians are ideally placed to screen for OSA and EDS in patients who present with commonly comorbid conditions such as obesity, cardiovascular disease, metabolic syndrome, and depression. Conversely, treatment of OSA and associated EDS might help alleviate significant comorbidities and their clinical and societal consequences.

Background: Insulin therapy may eventually be required to maintain glycemic control in many patients with type 2 diabetes mellitus. Premixed insulin analogues offer relatively physiologic and predictable time-action profiles and are available in more convenient delivery systems with finer needles than in the past. They also increase the convenience of administration with respect to mealtimes compared with premixed human insulin, and reduce the number of injections compared with basal-bolus therapy. Objective: This manuscript describes the development of premixed insulin analogues, reviews efficacy and safety data from randomized trials of premixed insulin analogues compared with human insulin 70/30 or basal insulins, and discusses their use for the management of type 2 diabetes. Methods: English-language randomized clinical trials comparing premixed insulin analogues with either premixed human insulin formulations or basal insulins for the treatment of type 2 diabetes, published through May 2005, were identified using PubMed. Pharmacokinetic and pharmacodynamic studies were also included. Abstracts presented at the meetings of the American Diabetes Association, International Diabetes Federation, and the European Association for the Study of Diabetes in 2003 and 2004 were also reviewed. Results: Premixed insulin analogues allow delivery of both basal and prandial insulin in 1 injection and are more convenient than premixed human insulin formulations. The rapid-acting component is absorbed and cleared more quickly, thereby allowing mealtime administration and providing better postprandial glycemic control. Although there is an increased risk of minor hypoglycemia, 3 comparative, randomized trials have shown that patients using premixed analogues twice daily are more likely to reach glycosylated hemoglobin (HbA 1c ) goals compared with those using only insulin glargine once daily. Premixed insulin analogues are available in vials, pens, and dosers. Conclusions: Premixed insulin analogues have a more physiologic time-action profile, can be administered closer to mealtime, and produce greater reductions in the magnitude of postprandial glucose excursions than human insulin 70/30. Despite these advantages, no consistent differences in HbA 1c reduction or the incidence of hypoglycemia versus human insulin 70/30 have been found in most short-term trials. Although there is an increased risk of minor hypoglycemia, patients using premixed insulin analogues twice daily are more likely to reach HbA 1c goals than those using only insulin glargine once daily. Further studies are necessary to examine whether these advantages improve patient outcomes in clinical practice.

This report presents results from an international multicenter trial of the safety of buspirone in the treatment of anxiety disorders for periods up to one year, if needed; 424 patients were treated for six months, and 264 patients completed a full year of treatment. Chronic use of buspirone for up to 52 weeks was associated with emergence of no new or unexpected side effects that were not previously reported during shorter periods of treatment. Most patients were successfully managed on daily doses ranging from 15 to 30 mg/day. When buspirone therapy was abruptly discontinued after more than six months of therapy, assessments of patients yielded no evidence of a withdrawal syndrome or unusual events. Although long-term anxiolytic drug therapy is not generally recommended, this open study provides evidence of the potential usefulness of buspirone when used for up to one year. As a general guideline, when an anxiolytic agent is used for several months or longer to treat chronic anxiety, the need for drug therapy should be reevaluated periodically.

This is the most thorough discussion of the relationship between the caduceus and medicine that has been written. Friedlander, a Professor Emeritus of Medical Humanities at the University of Nebraska, provides an in-depth analysis of how the caduceus, the wand of the Greek god Hermes (the Roman Mercury), has come to be inappropriately used by some as the symbol of medicine. The Golden Wand of Medicine is an excellent historical analysis with good documentation of the facts and sources, but it is relatively dull reading. Take, for example, the two chapters about Hermes. The author describes in detail the various Greek Hermes—the pre-Homeric Hermes, the archaic Hermes, and the traditional Hermes—then devotes another chapter to the Egyptian Hermes—Hermes-Thoth, Hermes Trismegistus, and Pseudo Hermes Trismegistus—more than you ever wanted to know about Hermes. The evolution of the caduceus is traced from its first appearance in the seventh century BCE to its

Anxiety disorders are among the most common psychiatric conditions. 1 Like depressive and substance use disorders, with which they often coexist, they begin early in life. At least 5% of the US population (12 million people) annually experience anxiety severe enough to seek treatment. 2 Anxious individuals are heavy users of the health care system, accounting for 10% to 15% of patient visits to internal medicine and cardiology practices. 3 Therefore, this review, which summarizes recent advances in anxiety disorders, is relevant to all physicians. When evaluating an anxious patient, the physician must first decide whether the anxiety is an appropriate response to a threatening situation or represents a pathologic entity. If the latter, the physician should then determine if it is due to a medical condition known to cause anxiety or if it is the manifestation of a psychiatric disorder. Finally, the condition should be assigned to a specific

Trazodone demonstrates comparable efficacy with the tricyclic antidepressant agents (TCAs) but produces fewer of the untoward side effects associated with these drugs. All of the TCAs are potentially lethal when taken in overdose; they cause serious cardiovascular side effects; produce anticholinergic effects, which often are severe enough to result in discontinuation of medication; and impair cognition, especially in elderly patients. In contrast, trazodone is relatively safe when taken in overdose; no deaths have been reported to the manufacturer when trazodone was the only agent taken. Trazodone produces fewer and milder cardiovascular disturbances and anticholinergic effects than TCAs. If anticholinergic side effects do occur then they are rarely bothersome enough to result in discontinuation of therapy. In addition, cognitive skills, even in elderly patients, are less impaired in patients receiving trazodone therapy than in patients receiving TCA drugs. Although trazodone therapy has been associated with lethargy, dizziness, drowsiness, and confusion in some patients, symptoms have been mild and can be further minimized by administering the drug either after meals or once daily at bedtime.

A nationwide study investigated the attitudes of family practice residents toward: (1) interdisciplinary health care teams in family practice; (2) the clinical pharmacist as a member of the health care team; and (3) the utility of clinical pharmacist involvement in private family practice offices. A random sample of 174 family practice residency programs was selected for study. First-year residents comprised the sample population. Based on the response of the directors, programs were assigned to experimental (programs offering clinical pharmacy services) or control (no clinical pharmacy services) groups. Completed attitudinal instruments were received from 158 resident respondents in the experimental group and 153 resident respondents from the control group. The reliability coefficient of the returned questionnaires was 0.901 by the split-halves method. Residents in the experimental group had significantly more favorable attitudes than those residents in the control group on several scales. These scales included the clinical pharmacist's participation on the health care team, utility of a clinical pharmacist in a private practice setting, desirability of hiring a clinical pharmacist, and the desirability of practicing with a multidisciplinary health care team. These results support the hypothesis that exposure to clinical pharmacy services can significantly affect physician resident's attitudes toward clinical pharmacy.

Ballistocardiographic studies were made in 41 patients; with diabetes since childhood. A high incidence of abnormalities was observed. The possible diagnostic and prognostic implications are discussed.

H pylori infection is so common as to seem ubiquitous in many areas of the world. Transmission is believed to be primarily person to person. The pathogen invariably damages the gastric mucosa, resulting in both structural and functional abnormalities. It causes histologic gastritis and is critical in the pathogenesis of the gastritis-associated diseases, namely, gastric ulcer, duodenal ulcer, gastric adenocarcinoma, and primary gastric lymphoma. Elimination of the infection results in healing of gastritis and cure of peptic ulcer disease.

In this issue ofThe Journal(p 63), Culpepper and Franks have succinctly identified the problems facing research in family medicine in its second decade. Although the federal government has recognized the need for improved primary care, such improvement cannot occur without an equivalent emphasis on research to develop new knowledge and improved skills in this area. Unfortunately, this need occurs at a time when the federal government is reducing its commitment to research and is unlikely to shunt remaining funds away from other areas. If primary care is to be the base for an efficient health care system, however, adequate resources must be devoted to improving the knowledge and developing the skills to do this well. Residency training has improved the quality of care provided by family physicians. We now need to pursue vigorously the expansion of knowledge in family medicine. Federal research funds have traditionally gone to academic

The staff of Aesculapius has represented medicine since about 800 BC, and most authorities support its use as the symbol of medicine. The Encyclopaedia Britannica agrees: "This staff is the only true symbol of medicine." Why, then, is the caduceus, which had never been chosen to represent medicine until after 1800, so frequently being adopted as the symbol of medicine? And is the twin-serpent magic wand of Hermes (later the Roman Mercury), messenger of the gods and protector of merchants and thieves, an appropriate symbol for the medical profession? The word caduceus is derived from a Greek root meaning "herald's wand." The Romans were said to have used the caduceus as a badge of neutrality among heralds seeking peaceful negotiations with the enemy. Hart 1 notes that the beginning of the use of the caduceus as a medical symbol in the United States dates back to 1856, when it was selected

Although the annual consumption of chewing tobacco in the United States is 81 million pounds, 1 practically no information is available about its clinical or physiological effect or specifically about its effect on the heart and circulation. 2 To advise patients who are habitual chewers regarding chewing, it is important to know what changes in the pulse rate or rhythm, blood pressure, skin temperature (reflecting peripheral vasoconstriction), ballistocardiographic wave forms, arrhythmias, and circulation may be produced by chewing tobacco. Accordingly, men who chewed tobacco habitually were studied before, during, and after chewing both standard commercial tobacco (1.53% nicotine) and low-nicotine tobacco (0.31 to 0.47% nicotine). In addition, a questionnaire was sent to distinguished cardiologists, internists, and other physicians interested in peripheral vascular diseases to learn their experience with the effects of chewing tobacco on the heart or circulation. None had had personal experience with the effects of chewing tobacco on