Editor-in-Chief: Ilkka Kunnamo
Publisher: Duodecim Medical Publications (March 2005)
Reviewer: Meteb Al-Foheidi, Medical Resident, University of Toronto

When I was originally asked to review this book, I anticipated examining a pocket-sized guide, but I was surprised to receive a textbook-sized volume running1,311 pages.

When I started to review this book, I tried to cover some topics that I knew and others that I had little knowledge about. At the time I delved in I was doing my emergency medicine rotation, where I was exposed to a wide variety of surgical and medical emergencies in an urban academic hospital. I planned to check every case that I encountered in the Emergency Room with the information contained in the book. For instance, I had an allergic rhinitis case, and I went looking for this in the book. In this and other cases, the text proved to be a good resource: the material was informative and clear, and it provided me with the ARIA guidelines and classifications.

The guide is further enhanced by its thorough forward, preface, and list of abbreviations. It also features good-quality cover design and material.
However, readers should be aware of a few flaws. First, I noted several spelling mistakes (for example, the word “Pheo” was written as “feo”). Second, main chapters were not categorized properly for easy searching. Generally, each chapter dealt with a specialty (e.g., cardiology or pediatrics). But there were some chapters that should have been subchapters within specific specialties: diabetes should fall under endocrinology and birth control under obstetrics and gynecology. While they were likely allotted their own chapters because they are extensively studied conditions or categories, I found it poor on the level of organization.

Furthermore, sections under chapters were improperly categorized. This may cause confusion or even make it difficult to find the information easily without going through all of the contents’ subsections. For instance, page 89 featured material about Hospital Investigations. The first point referred readers to a page still further ahead, page 100, which was about “Secondary Hypertension.” Sending readers back and forth to read about one subject should be avoided.
Other examples of poor organization included chapter content. Some chapters were diseases and others were symptoms. For example, Pulmonary Diseases started with Hemoptysis. Etiologies such as infections, tumours, cardiovascular disease, trauma, etc., were discussed. Then under Differential Diagnosis, the authors addressed the importance of the patient’s history, clinical examinations, and chest x-ray, which are essential for differential diagnosis. As another example of disorganization, the writers opted to explore specific diseases of the respiratory system within a chapter dealing with a symptom.

Some chapters were not evidence-based such as Occupational Health and Pollution—a concern in a text devoted to evidence-based guidelines.
Regarding references: the textbook mentioned only grading references, but no tables or summary and references were listed at the end of each section. In my opinion, this kind of book should contain tables, easy-to-follow flow charts, and summaries that are specific to that section.

The book should have been devoted to guidelines only, based on the title, but the authors/editors went beyond that and added information that one would only find in general medical textbooks and reference guides, such as adding detailed definitions, epidemiology, clinical presentations, and investigations that lacked connection to either guidelines or to evidence-based medicine. Thus the book deviates from its title and is a hybrid of evidence-based guidelines and a standard textbook.

My overall assessment of this book: I believe it will be helpful for the generalists for whom this book was intended. As for me, I will keep this copy on my shelf and I will use it for topics outside my specialty, internal medicine. It will be more useful as a general reference for me in other areas such as surgery, pediatrics, and so forth.

Norm R.C. Campbell, MD, FRCPC, Division of General Internal Medicine, University of Calgary, Calgary, AB.
J. George Fodor, MD, FRCPS, PhD, Ottawa Heart Institute, Ottawa, ON.
Robert Herman, MD, FRCPC, Division of General Internal Medicine, University of Calgary, Calgary, AB.
Pavel Hamet, MD, FRCPC, PhD, Research Center, CHUM, Montréal, QC (for the Canadian Hypertension Education Program).

Hypertension is a leading risk for morbidity and mortality in Canada. The older population is at greater risk from hypertension and has a greater reduction in cardiovascular risk with treatment than young patients. Frequent screening for hypertension is prudent as the estimated risk of developing hypertension is about 90%, even in normotensive 65-year-olds. Systolic blood pressure is a more relevant risk factor than diastolic blood pressure in older patients and is more difficult to treat to target. Most hypertensive patients will have multiple cardiovascular risks that require screening and management to reduce cardiovascular risk optimally. Lifestyle therapy is efficacious. Effective first-line drug therapies that reduce hypertension complications include thiazide-type diuretics, ACE inhibitors, long-acting calcium-channel blockers, and angiotensin-receptor blockers. Most patients require two or more drugs to achieve current blood pressure targets.
Key words: high blood pressure, hypertension, guidelines, recommendations, evidence-based medicine.

Ashraf Alzaabi, MD, FRCPC, Respirology Fellow, University of Toronto, Toronto, ON.

Theodore K. Marras, MD, FRCPC, Respirologist, Toronto Western Hospital, University Health Network; Assistant Professor of Medicine, University of Toronto, Toronto, ON.

Community-acquired pneumonia (CAP) in the older adult is a common disease with significant mortality. This review focuses on the management of CAP, with specific reference to the older adult. Common etiologic organisms and organism-specific risk factors that tend to be associated with increasing age are presented. A systematic approach is described to help physicians decide on the best treatment site (ambulatory, long-term care facility, or acute care hospital). The rationale behind initial empiric antibiotic therapy and drug resistance are discussed. Recent guidelines for the selection of empiric antibiotic therapy are compared and a synthesis of guidelines for antibiotic selection and recommendations regarding parenteral to oral switch-therapy are presented. Guidelines are suggested to help the physician safely discharge the patient home.

Key words: pneumonia, management, older adults, guidelines, resistance.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Lianne Tile MD, FRCPC, M Ed, Staff Physician, Osteoporosis
Program and Division of General Internal Medicine, University Health Network, Toronto, ON

Osteoporosis and fractures are a common cause of morbidity in postmenopausal women. Women age 65 and older, and those with risk factors for bone loss, should be screened by DEXA. When osteoporosis is diagnosed, secondary causes need to be considered. Fracture risk is determined by bone mineral density, age, prior fracture, and family history of osteoporosis. Adequate calcium and vitamin D intake and regular exercise are essential for the prevention and treatment of osteoporosis. Pharmacologic therapy should be used based on fracture risk. Patient preferences and side effect profile must be considered in choosing among several effective treatment options.
Key words: osteoporosis, treatment, postmenopausal, diagnosis, guidelines

Definition and Epidemiology
Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture.

A Review of the Literature

Alan K. Berger, MD, Sections of Cardiology and Epidemiology, University of Minnesota, Minneapolis, MN, USA.

While elderly patients (aged = 75 years) represent a small segment of the general population, they account for disproportionate morbidity and mortality associated with acute myocardial infarction. Consequently, the efficacy and utilization of reperfusion therapy--thrombolysis and primary coronary angioplasty/stenting--remain highly relevant. A randomized clinical trial of thrombolysis in the elderly has never been performed, although subgroup analyses have suggested a benefit. The effectiveness of thrombolysis in the elderly has been challenged by observational studies documenting unexpectedly high mortality. The efficacy of primary coronary angioplasty/stenting is now well established and growing evidence suggests this approach is superior to thrombolysis in the elderly.
Key words: geriatrics, thrombolysis, primary coronary angioplasty, acute myocardial infarction, guidelines.

D'Arcy Little, MD, CCFP
York Community Services, Toronto and
Department of Family Medicine, Sunnybrook Campus of Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario

Epidemiology
Diabetes mellitus, a metabolic disease characterized by hyperglycemia secondary to defective insulin secretion and/or action, is an extremely common, chronic illness with a high burden of potentially preventable complications. It is a leading cause of coronary artery disease, peripheral vascular disease, kidney failure, peripheral neuropathy and new-onset blindness. A full five percent of Canadians have been diagnosed with the disease, and this percentage is predicted to translate into 2.2 million cases by the year 2000. However, statistics from the United States suggest that for every person diagnosed with diabetes, another has the disease and remains undiagnosed. Appropriate screening for diabetes provides the means to identify those undiagnosed individuals who may benefit from earlier intervention.