Ethanol has long been recognized as a toxic agent that has acute and chronic effects on cerebral and hepatic function. Over the past two decades important influences on the cardiovascular system have been either rediscovered or observed for the first time. The combined use of tobacco cigarettes and alcohol appears to increase the risk of many of these clinical abnormalities. While many individuals addicted to ethanol have subclinical abnormalities of the heart, somewhat less than a majority develop symptomatic cardiac problems. These include heart failure and arrhythmias. In addition to supraventricular arrhythmias that often normalize spontaneously, there is an increased incidence of sudden death that peaks at about 50 years of age in the alcoholic population. A significant degree of blood pressure elevation occurs in individuals who abuse alcohol. This appears to be transient and is normalized in most individuals during abstinence. The increased incidence of hemorrhagic and nonhemorrhagic stroke in middle age also appears to decline when alcohol abuse is interrupted. A preventive effect of mild to moderate drinking on coronary artery disease is, at present, equivocal, largely due to the question of appropriate controls.

Evidence suggests a significant association between use of psychoactive substances among adolescents and suicidal behavior among adolescents during the past two decades. Accumulating evidence, although not unanimous, supports the hypothesis of psychoactive substance abuse among adolescents as a risk factor for a range of suicidal behavior--ideation, attempted suicide, and completed suicide. With increasing rates of psychoactive substance abuse for the adolescent population during the past 20 years, this appears to be an increasingly important factor. It is not known if the association is causal. Psychoactive substance abuse appears to be associated with a greater frequency and repetitiveness of suicide attempts, more medically lethal attempts, a measured seriousness of intention, and greater suicidal ideation. Additional data support a specific association between alcohol intoxication and suicide by firearms among adolescents. Adolescents who abuse psychoactive substances, particularly those with any type of depressive disorder, appear to be at higher risk for suicidal behavior and may need appropriate psychiatric treatment.

Cor pulmonale is right ventricular enlargement secondary to pulmonary hypertension. Although most often caused by parenchymal lung disease, derangements of the ventilatory drive, the respiratory pumping mechanism, or the pulmonary vascular bed may also result in right ventricular hypertrophy and dilatation. Arterial hypoxemia (and resultant polycythemia), hypercapnia, and respiratory acidosis all contribute to the increased afterload on the right ventricle. Diagnosis is often difficult, since pulmonary vascular disease, pulmonary hypertension, and cor pulmonale have few specific manifestations, especially early in their evolution. Treatment is primarily directed at the underlying pulmonary or ventilatory disorder, rather than at the right ventricular failure per se. Supplemental oxygen is essential to avoid hypoxia; corticosteroids, anticoagulants, vasodilators, and other specific therapies are used as indicated to treat the underlying pulmonary disorders. When medical therapies fail, lung or heart-lung transplantation has become a possibility for selected patients.

Persistent, and sometimes substantial, differences continue to exist in the quality of health among Americans. Blacks have higher infant mortality rates and shorter life expectancies than whites. Underlying the disparities in the quality of health among Americans are differences in both need and access. Moreover, recent studies have suggested that even when blacks gain access to the health care system, they are less likely than whites to receive certain surgical or other therapies. These studies have examined treatments in several area, including cardiology and cardiac surgery, kidney transplantation, general internal medicine, and obstetrics. Whether the disparities in treatment decisions are caused by differences in income and education, sociocultural factors, or failures by the medical profession, they are unjustifiable and must be eliminated. In this report, the Council on Ethical and Judicial Affairs of the American Medical Association emphasizes the need for (1) greater access to necessary health care for black Americans, (2) greater awareness among physicians of existing and potential disparities in treatment, and (3) the continued development of practice parameters, including criteria that would preclude or diminish racial disparities in health care decisions.

Hyperbaric oxygen therapy involves intermittent inhalation of 100% oxygen under a pressure greater than 1 atm. Despite over a century of use in medical settings, hyperbaric oxygen remains a controversial therapy. The last 20 years have seen a clarification of the mechanism of action of hyperbaric therapy and a greater understanding of its potential benefit. However, despite the substantial evidence that hyperbaric oxygen may have a therapeutic effect in certain carefully defined disease states, many practitioners remain unaware of these findings or are concerned about using hyperbaric therapy because of the controversy it has engendered. This review examines the indications currently considered appropriate for hyperbaric oxygen and briefly evaluates animal and clinical data substantiating these indications. Areas in which the mechanism of action of hyperbaric oxygen is still not well understood, as well as possible new areas of applications, are discussed.

Advances in medical technology and practices have been associated with improved patient outcomes. At times, the price of this progress has included great financial costs and human suffering. During the last two decades, there have been significant changes in medical practices in America. In the late 1960s and early 1970s, the removal of a respirator or hydration or nutrition from a patient who was not brain dead was considered a deviation from accepted medical practices. In 1976, the Quinlan case allowed the removal of a ventilator from a patient in a persistent vegetative state. Subsequent court decisions in the 1980s have equated hydration and artificial feeding with other forms of life-sustaining treatments and have allowed their withdrawal in patients who were not terminally ill. Prominent physicians have recently stated that it is not immoral for a physician to assist in the rational suicide of a terminally ill patient. Active euthanasia programs in the United States are likely in the near future.

Health education efforts have grown dramatically over the past decade and seek to improve the health of individuals by providing them with information that will lead to behavioral changes and thereby result in improved health. There is now substantial evidence to support the idea that health education activities can alter health behaviors, even though the mechanisms by which health education efforts succeed are largely unknown. Physicians could add to the success of health education efforts by incorporating preventive services into their patient encounters, particularly patients in high-risk situations. There are many examples of successful physician-based interventions, and a new emphasis on preventive services in primary care is emerging.

The prevalence of menstrual dysfunction is greater among athletes than in the general population. Many factors undergo change during the course of an athletic training program and any or all of these may contribute to disturbances in menstrual cyclicity. All athletes with oligomenorrhea, amenorrhea, or menarcheal delay require thorough evaluation to rule out serious pathological conditions, since the diagnosis of exercise-associated menstrual dysfunction can be made only by excluding other etiologic factors. Most athletes who have these problems should be treated to prevent undesirable sequelae.

Complications of acute myocardial infarction that develop within the first 2 weeks after its onset have been associated with a poor prognosis and dismal surgical outcome. In recent years, aggressive use of hemodynamic monitoring and interventions that improve myocardial oxygen supply and demand have noticeably altered the prognosis. Urgent relief of myocardial ischemia with coronary reperfusion has had the largest impact in improving the results. Surgical treatment of mechanical and nonmechanical complications of acute myocardial infarction requires prompt decision making and expeditious implementation. Persistent left ventricular dysfunction and cardiogenic shock are the most important factors that influence the overall results.

Home care is a rapidly growing field that is beginning to attract greater physician interest and participation. Cost-containment pressures have led to reduced institutionalization in hospitals and nursing homes and to more patients, both acutely and chronically ill, being cared for in their own homes. Undergraduate and graduate medical education programs are developing home care curricula, and academic medicine is beginning to develop a research agenda, particularly in the area of clinical outcome measurements. Medical care in the home is highly diversified and innovative. The areas of preventive, diagnostic, therapeutic, rehabilitative, and long-term maintenance care are all well represented as physicians develop new practice patterns in home care.

Information management constitutes a major activity of the health care professional. Currently, a number of forces are focusing attention on this function. After many years of development of information systems to support the infrastructure of medicine, greater focus on the needs of physicians and other health care managers and professionals is occurring--to support education, decision making, communication, and many other aspects of professional activity. Medical informatics is the field that concerns itself with the cognitive, information processing, and communication tasks of medical practice, education, and research, including the information science and the technology to support these tasks. An intrinsically interdisciplinary field, medical informatics has a highly applied focus, but also addresses a number of fundamental research problems as well as planning and policy issues. Medical informatics is now emerging as a distinct academic entity. Health care institutions are considering, and a few are making, large-scale commitments to information systems and services that will affect every aspect of their organizations' function. While academic units of medical informatics are presently established at only a few medical institutions in the United States, increasing numbers of schools are considering this activity and many traditional departments are seeking and attracting individuals with medical informatics skills.

Youths who are detained or incarcerated in correctional facilities represent a medically underserved population that is at high risk for a variety of medical and emotional disorders. These youths not only have a substantial number of preexisting health problems, they also develop acute problems that are associated with their arrest and with the environment of the correctional facility. Although the availability of medical services varies by the size of the institution, established standards are, in general, not being met.