Over the past decade, numerous impressive advances have been made using nonpharmacologic methods for control of cardiac arrhythmias. These methods include surgical or catheter ablation of abnormal foci. Current techniques involve catheter ablation of the atrioventricular junction to control supraventricular arrhythmias. In addition, surgical techniques have proved to be remarkably safe and effective for treatment of patients with accessory pathways and those with atrioventricular nodal reentrant tachycardia. Patients with drug-refractory ventricular tachycardia may benefit from surgical resection of the ventricular tachycardia focus. The use of these interventional methodologies has radically altered the approach to management of patients with drug-refractory cardiac arrhythmias.

Primary care physicians and nurses have numerous opportunities to assist in the prevention of dental caries, periodontal diseases, malocclusion, trauma to the mouth and teeth, and oral cancer. This is the first of two articles that provide background for the US Preventive Services Task Force recommendations for interventions by physicians, nurses, and other clinicians to prevent these oral diseases and conditions. Physicians and other health professionals are urged to be aware of these opportunities and to take appropriate action in collaboration with the patient's dentist.

Many diagnostic studies and procedures are available for the evaluation of jaundice. By judicious selection of those that are most likely to lead to a prompt diagnosis and by weighing their relative risk and efficacy, the physician can better ensure the comfort and safety of the patient and the cost-effectiveness of medical care. A guideline is presented that recommends an approach to the evaluation of jaundice. It is based on a critical review of the literature and its application to clinical practice.

Using criteria adopted by the US Preventive Services Task Force, we evaluated use of the dipstick urinalysis to screen for bacteriuria. When the leukocyte esterase and nitrite dipstick tests are combined, the positive predictive value for detecting bacteriuria exceeded 12% in groups with a 5% or higher prevalence of bacteriuria: women who are pregnant, diabetic, or over 60 years of age and all institutionalized elderly. Conventional antimicrobial regimens for asymptomatic bacteriuria have proved efficacious only for pregnant women. We conclude that pregnant women should be screened for bacteriuria, but with the more sensitive urine culture, because treatment prevents serious fetal and maternal sequelae. Dipstick screening may be justified in women who are over 60 years of age or diabetic. The prevalence of bacteriuria in other groups is too low to justify screening.

We review evidence on the value of dipstick urinalysis screening for hemoglobin and protein in asymptomatic adults. In young adults, evidence from five population-based studies indicates that fewer than 2% of those with a positive heme dipstick have a serious and treatable urinary tract disease, too few to justify screening and the risks of subsequent workup. For older populations, evidence is contradictory and no recommendation can presently be made for or against hematuria screening. A population-based randomized, controlled trial of hematuria screening in the elderly is urgently needed. Proteinuria screening is not recommended in any healthy, asymptomatic adult population, since four population-based studies have found that fewer than 1.5% of those with positive dipsticks have serious and treatable urinary tract disorders.

In 1985, breast cancer will be diagnosed in approximately 120,000 women; in 90% of these women, the disease will apparently be limited to the breast and axillary lymph nodes. Despite advances in early diagnosis and primary treatment with surgery, radiation therapy, or both, more than a third of these patients will develop systemic disease and ultimately die. In the broadest sense, all of these patients are potential candidates for some form of systemic adjuvant therapy. Adjuvant therapy of breast cancer involves the use of cytotoxic drugs or endocrine therapy after definitive primary therapy. The rationale is to eradicate occult metastatic disease that otherwise would be fatal. The goal of adjuvant therapy is to significantly prolong survival, while maintaining an acceptable quality of life. Three measures are important in evaluating whether this goal is met by specific treatments: 1. The effect of therapy on overall survival: the length of time a woman survives following a diagnosis of breast cancer. 2. The effect of therapy on disease-free survival: the length of time a woman remains free of any recurrence of disease. Prolonged periods of disease-free survival may be advantageous in their own right, since quality of life is likely to be better before than after relapse. There is also some evidence that longer periods of disease-free survival may translate into better overall survival rates. 3. The effect of therapy on quality of life: in choosing an adjuvant therapy program, potential benefits must be balanced against both short-term and long-term side effects. Also important are the substantial psychological, social, and economic problems women may experience as a result of treatment. An increasing number of important prognostic variables have been identified that define the natural history of breast cancer. These include well-established factors such as histological status of axillary lymph nodes, primary tumor size, steroid hormone receptors, menopausal status or age, and histopathology. Assessment of cell differentiation and proliferation, which can be determined by newer techniques, may also be significant. The pathological status of the axillary lymph nodes remains the single most important prognostic variable, and four lymph node categories have been defined (negative, one to three positive nodes, four to nine positive nodes, and ten or more positive nodes). Since definitions of menopausal status vary widely among clinical trials, age (less than 50 vs greater than or equal to 50 years) can be substituted as a prognostic variable.(ABSTRACT TRUNCATED AT 400 WORDS)