Edward R. Bollard

The Evidence-Based Evaluation of Iron Deficiency Anemia

Anemia is a prevalent disease with multiple possible etiologies and resultant complications. Iron deficiency anemia is a common cause of anemia and is typically due to insufficient intake, poor absorption, or overt or occult blood loss. Distinguishing iron deficiency from other causes of anemia is integral to initiating the appropriate treatment. In addition, identifying the underlying cause of iron deficiency is also necessary to help guide management of these patients. We review the key components to an evidence-based, cost-conscious evaluation of suspected iron deficiency anemia.

Gastric Diverticulum: A Rare Cause of Refractory Epigastric Pain

A 60-year-old man, with a past medical history of “hearturn” for 7 years and a diagnosis of functional dyspepsia ollowing a normal esophagogastroduodenoscopy study 5 ears prior, presented with worsening epigastric pain. The ain had been increasing for the last 2 months and had ecome refractory to over-the-counter histamine-2-blockde and proton-pump inhibition. It was sharp in quality, adiating to his back, not related to meals or exertion, and ot associated with nausea, vomiting, change in bowel habts, or weight loss. Computed tomography scan revealed a

A Convergence of Themes: Making Evidence-Based, High Value Choices

It would probably not be accurate to say that medicine is undergoing a revolution. It is more likely that the idea of “revolution” has been repeatedly applied to what has been evolving in health care in each of the last 50 years. We believe it is more accurate to state that each generation of physicians faces its own struggles, its own challenges, and its own opportunities and strives to implement its own innovations. In addition, each generation of physicians has nostalgic notions of what medicine used to be and anxiety about what medicine should and will be in the future. Over the past 20 years, there has been an increased reliance and respect for evidence-based medicine, quality improvement, population health, using data to drive clinical changes, efficiency and effectiveness, and high-value care. In addition, there has been an outcry for patient centeredness, patient safety, shared decision making, and the importance of the provider/patient relationship. Given this multitude of interests and themes, each with its own tag name, many physicians have grown weary of the “next thing.” In an effort to keep up with these evolving trends, many health systems have adopted short-term, sometimes shortsighted, incentives for the latest “trends.” This has often occurred at the expense of practicing clinicians, who have been bludgeoned by electronic health records, quality metrics, pay for performance, and whatever “theme du jour” that happens to be invoked for that particular timeframe. As physicians who have witnessed massive changes over the last several decades, we now see that we are not merely on the precipice of the “latest and greatest” in health care, but rather at a convergence of the themes that have most recently dominated the improvement of health care. We see that all of these themes—managed care, evidence-based medicine, patient-centered care, quality and system improvement, shared decision making, bending the cost curve, and population health—are

Medical Care for Kidney and Liver Transplant Recipients

As transplant medicine has evolved, so has the role of the generalist in the ongoing care of the patients receiving these vital organs. Liver and kidney transplantation, once considered a highly specialized area of surgery, has become quite common. The patient care it demands has resulted from not only the care related to the organ itself but also the types and degree of immunosuppression, as well as the inherent potential for complications that surround it. As the number of patients receiving cadaveric and living donor–related liver and kidney transplants has increased—and their life expectancy has lengthened—the need to involve the primary care physician in their care has become essential. In this issue of the Medical Clinics of North America, Drs Sass and Doyle have assembled an exceptional panel of experts to address the common, yet complex, questions that present to the internal medicine physician whose patients undergo transplantation of these organs. The editors begin by providing the historical perspective to liver and kidney transplantation. The articles to follow address almost every aspect of the subsequent care of these patients (and donors), from determination of the time to transplant, discussion of immunosuppression and the potential shortand long-term complications, to the impact on quality of life and the potential for pregnancy in the transplanted patient. If not now, then in the very near future, all of our practices will be providing longitudinal care to patients who have undergone liver and/or kidney transplantation. The articles in this issue present a breadth and depth of knowledge that will allow

Common Musculoskeletal Problems in the Ambulatory Setting

Musculoskeletal complaints are one of the most common reasons patients seek care from their primary care physicians. Of these presenting complaints, it is estimated that 90% of the nonsurgical orthopedic conditions can be managed in the primary care setting. In this issue of the Medical Clinics of North America, Dr Matthew Silvis and his colleagues address many of these common musculoskeletal conditions that make up the 10 to 15% of all visits to primary care offices. Reviews have previously noted the inadequate examinations and inappropriate ordering of tests and procedures that often occur when a comprehensive understanding of a focused history, musculoskeletal examination, and diagnostic approach is not undertaken. As we continue to emphasize the need for exercise and physical activity in our patients with the reality that we are asking this of a population that continues to advance in age, the skills of the primary care physician to appropriately diagnose and efficiently treat these conditions will be essential. The ultimate goal for our patients will be the return to functional status and management of symptoms that will allow them to reengage in the activities that will promote their overall wellness.

Oral Medicine: A Handbook for Physicians

An area of medicine that is frequently overlooked, often misunderstood, and potentially goes undertreated or untreated when signs and symptoms arise is pathology of the oral cavity and associated structures. In both ambulatory and hospital settings, diseases, dysfunction, and trauma of the teeth; periodontal tissues; bony elements; soft tissue structures; and salivary glands provide diagnostic challenges to the treating physician when she or he does not possess a thorough understanding of oral anatomy as well as oral medicine. In June 2008, the Association of American Medical Colleges (AAMC) in collaboration with the American Dental Education Association, understanding the deficiencies in oral medicinethattraditionalmedicalschoolcurriculacontain,publishedareportofanexpert panelaspartoftheMedicalSchoolObjectivesProjectentitled,“ContemporaryIssuesin Medicine:OralHealthEducationforMedicalandDentalStudents.” 1 Thiswasanattempt to highlight and close the gaps in knowledge that exist in those who will be called on to evaluate the diseases of and related to the oral cavity in the practice of medicine. In this issue of the Medical Clinics of North America, Dr Stoopler, Dr Sollecito, and colleagues present nine articles that also attempt to reduce this knowledge gap by emphasizing the normal anatomy, common anatomic variations, as well as relevant orofacial pathology that can be applied to our comprehensive care of the medical patient.