DEDICATED TO LIFELONG LEARNING SEPTEMBER 1999 lb J VOLUME 66 • NUMBER 8 • ISSN 0891-1150 AND JNIC TABLE OF CONTENTS JÖURNAIPF MEDICAL GRAND ROUNDS MEDICINE n Palliative care: Clinical approach 459 to chronic pain and intestinal obstruction JOHN D. CLOUGH, MD Editor-in-Chief LINDA K. HENGSTLER Editor and Publisher Oral medications should control pain in up to 80% PHILLIP E. CANUTO Executive Editor of patients with terminal cancer. Yet, many patients RAY BORAZANIAN Managing Editor receive inadequate pain treatment. DAVID A. HUDDLESTON Manuscript Editor LOUISA R. PASKERT Editorial Assistant G. HANKS AUDRA BUTDORF Editorial Assistant/Reprints JESSICA ANCKER Editorial Services BRUCE M MARICH Production Manager JOHN E. PRESSELLO Art Director MEDICAL GRAND ROUNDS ROBERT J. DEMAREST Medical Art Director NANCY HEIM, CMI Medical Illustrator Evidence-based medicine in everyday practice 461 A step-by-step guide to using evidence to answer EDITORIAL ADVISORY BOARD DAVID L. LONGWORTH.MD MUZAFFAR AHMAD, MD STEPHEN MAHONEY. MD specific questions, with the answers guided hy the patient's WILMA FOWLER BERGFELD. MD MAURIE MARKMAN, MD wishes and values. EMMANUEL L. BRAVO, MD ATUL C. MEHTA, MD RAY W. GIFFORD, JR, MD NEIL B. MEHTA, MD G. GUVATT WILLIAM R. HART, MD FRANKLIN A. MICHOTA, MD ERIC A. KLEIN, MD STEVEN NISSEN, MD FLOYD D. LOOP, MD ROBERT M. PALMER, MD DOUGLAS S. MOODIE, MD VAKESH RAJANI, MD RICHARD H. NODAR, PHD NORMAN B. RATLIFF, MD WILLIAM L. PROUDFIT, MD S. SETHU K. REDDY, MD 1 -MINUTE CONSULT WILLIAM C. SHELDON. MD MARK ROTH, MD ERIC J. TOPOL, MD CATHY A. SILA, MD HERBERT P. WIEDEMANN, MD FRANCK SKOBIERANDA. MD Should one routinely screen 465 HOLLY L. THACKER, MD ASSOCIATE EDITORS JAMES THOMAS. MD for lipoprotein(a)? ALEJANDRO C. ARROLIGA, MD DONALD G. VIDT, MD DAVID BRONSON, MD WILLIAM S. WILKE, MD The evidence does not yet justify screening BEN H, BROUHARD, MD MARC WILLIAMS, MD WILLIAM D. CAREY, MD JAMES B. YOUNG, MD everyone, hut you may want to obtain an Lp(a) WILLIAM A. CHILCOTE, MD ZOBAIR YOUNOSSI, MD level if the LDL level remains high despite statin therapy. AMANDA L. CURNOCK, MD BRIAN G. DONLEY, MD CLEVELAND CLINIC J.P. FROLKIS GARY FRANCIS, MD FOUNDATION DIVISION STEVEN M. GORDON, MD OF EDUCATION GARY HOFFMAN, MD ANDREW J. FISHLEDER, MD BYRON J- HOOGWERF, MD ANIL K. JAIN, MD Chairman MANI S. KAVURU, MD PHILLIP R. GARD IM BOARD REVIEW MANDY C. LEONARD, PHARMD Administrator ANGELO A. LICATA, MD. PHD A 74-year-old woman 469 with abdominal pain and fever The Cleveland Clinic Journal of Medicine (ISSN 0891 -1150) is published 10 times What is the likely cause of this patient's symptoms? yearly by The Cleveland Clinic Foundation. A self-test on a clinical case. STATEMENTS AND OPINIONS expressed in the Cleveland Clinic Journal of Medicine are those of the authors and not necessarily of The Cleveland Clinic P. MAZZONE AND C. NIELSEN Foundation or its Board of Trustees. 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POSTMASTER ADDRESS CHANGES: Cleveland Clinic Journal of Mcine, Angiography is the gold standard for detecting coronary artery NA32,9500 Euclid Avenue, Cleveland, OH 44195 disease, but its results must be interpreted with caution. An SUBSCRIPTIONS, EDITORIAL, REPRINTS, AND PRODUCTION: (same acta as above) accompanying illustration shows why. Phone (216) 444-2661 • Fax (216) 444-9385 • E-mail, [email protected] http://www.ccjm.org S.E. NISSEN ADVERTISING: Joseph Dennehy, Director, Sales and Marketing, 120 Castle Ridge Rd, Manhasset, NY 11030 • Phone (516) 365-8640 • Fax (5161365-0587 CONTINUED ON PAGE 452 COPYRIGHT© 1999 THE CLEVELAND CLINIC FOUNDATION CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 66 • NUMBER 8 SEPTEMBER 1999 ,Effl PRINTED IN U.S.A. Downloaded from www.ccjm.org on September 30, 2021. For personal use only. All other uses require permission. SEPTEMBER 1999 BEGIN OCTOBER CONTINUED FROM PAGE 450 CARING FOR OLDER PATIENTS Hypertension in older persons: 487 Treatment reduces mortality, but is underused Despite compelling evidence that treatment reduces mortality, hypertension is undertreated, and especially so in older patients. A step-by-step approach, based on the latest recommendations from the NIH. w.s. ARONOW A 6-part series featuring REVIEW state-of-the-art 'Telephone treatment' 495 of uncomplicated acute cystitis diagnosis and Most women with uncomplicated acute cystitis can be treated over the telephone, saving time and money. treatment J. CAMPBELL, M. FELVER, AND S. KAMAREI FROM THE STAFF OF PATIENT INFORMATION THE CLEVELAND CLINIC HEART CENTER «Urinary tract infections 502 An illustrated patient-information sheet to copy RANKED FIRST IN CARDIAC CARE BY and give to your patient. US NEWS AND WORLD REPORT FOR THE 5TH CONSECUTIVE YEAR INFECTIOUS DISEASE ALERT Clostridium difficile diarrhea and colitis: 503 A clinical overview wmiv:.. In hospitalized patients who have received antibiotics, toxin-producing strains of C difficile can play havoc. A.J. TAEGE AND K.A. ADAL Definition and Pathogenesis of DEPARTMENTS Dear Colleague 455 Acute Coronary CME Credit Test 511 Syndromes BY VASANT PATEL AND ERIC TOPOL VISIT OUR WEB SITE AT HTTP://WWW.CCJIV!.ORG /~v The Cleveland Clinic Journal of Medicine is peer-reviewed and indexed in Index Medicus. CLEVELAND CLINIDownloadedC JOURNA Lfrom OF MEDICIN www.ccjm.orgE VOLUM onE 6September6 • NUMBER 30, 8 2021.SEPTEMBE ForR personal 1999 use only. All other uses require permission..