Heart DiseaseHeart Disease

Since the first edition in 1980, Braunwald's textbook Heart Disease has been considered by students, trainees, teachers, and practitioners of cardiology as a source of comprehensive and updated knowledge on cardiovascular diseases. Braunwald's stewardship has ensured the book's excellence. He has authored or coauthored a substantial portion of the chapters and maintained tight control over the material contributed by invited experts.

The text has managed to preserve a proper balance between basic science and clinical medicine. Broad knowledge and careful organization have enabled the editor to minimize duplications and prevent information from being repeated in diverse chapters–a common drawback of hastily collated multiauthored productions. The new edition retains the established assets of the book. The input of Braunwald's two new distinguished coeditors is recognizable in the reorganized and updated chapters on cardiac electrophysiology and arrhythmology coauthored by Zipes and in Libby's synthesis of the advances in the burgeoning field of vascular biology.

In the 4 years since the last edition, the textbook has accumulated about 300 additional pages of new material, an approximate 15% increase. The authors state in the preface that 30 of the 72 chapters are new, and the remainder have been extensively revised and updated. About half the authors contributed to the previous edition, and the rest are new.

The textbook is divided into eight sections. The first contains two new interesting chapters, one, by Gaziano, on the global aspects of cardiovascular disease and the other, by Hlatky, on the economics of cardiovascular disease. Subsequent sections are "Examination of the Patient," "Normal and Abnormal Cardiac Function," "Hypertensive and Atherosclerotic Cardiovascular Disease," "Diseases of the Heart, Pericardium and Pulmonary Vascular Bed," "Molecular Biology and Genetics" with a table of hundreds of phenotypes of cardiovascular disorders with recognized genetic defects and their loci on the gene map, "Cardiovascular Disease in Special Populations," and "Cardiovascular Disorders of Other Systems," which includes a new chapter on psychiatric and behavioral aspects of cardiovascular disease. An assortment of practice guidelines for management, evaluation, and prevention compiled by Lee is appended to the chapters in which such information can be useful.

The text reflects the increasing importance of the multiplying collaborative trials–bellwethers of cardiovascular care. A new chapter, "Relative Merits of Cardiovascular Diagnostic Techniques," by Beller, is a helpful guide to the choice of available imaging techniques. Advances in interventional cardiology, including extracardiac vascular therapeutic interventions, are thoroughly discussed. Other topics of new or updated chapters include molecular biology and coagulation disorders, clinical aspects of congenital heart disease in children and adults, and heart disease in patients with diabetes mellitus, in the elderly, and in athletes.

When planted on the desk or a sturdy shelf, the textbook (which weighs 11.5 lb) becomes most usable for an occasional review of a subject or a query that can be answered more quickly than by consulting the Web. An additional reward of having it is access to about 18 000 references, including hundreds of publications that appeared in the year 2000. Such a bibliography can serve as a convenient starting point for a literature search by teachers and writers. The book is lavishly illustrated, and the quality of the figures is excellent throughout. Also praiseworthy are the color photographs in the chapters on echocardiography and vascular biology and the inserted color plates. The detailed index will be helpful in the search for information.

The pace of progress in cardiology is breathtaking, and the new edition of Heart Disease captures this momentum. Those of us with a twinge of nostalgia for the old times will notice that the chapter on echocardiography is precisely twice as long as one on physical examination of the entire cardiovascular system, the chapter on HIV-related cardiovascular disease is nearly twice as long as that on rheumatic fever, and that in the treatment of cardiac arrhythmias amiodarone receives nearly twice as much coverage as digitalis. But, we cannot blame the messenger. This is an exemplary textbook that can well serve all professionals caring for cardiac patients who wish to broaden their knowledge of cardiovascular medicine.

This is the third book based on data from the 1992 National Health and Social Life Survey (NHSL) of sexual behavior in the United States. The first two books, The Social Organization of Sexuality and Sex in America, shared essentially the same material and were published simultaneously but were geared toward different audiences. Both books received widespread attention in the media as well as praise from professionals. Two of the four authors of the first two books, Edward O. Laumann and Robert T. Michael, edited this volume. They also coauthored most of the chapters with the help of other researchers and graduate students. Laumann is professor of sociology at the University of Chicago and Michael is professor and Dean of the Irving B. Harris Graduate School of Public Policy Studies, also at the University of Chicago.

Sex, Love, and Health in America has three sections: sex during adolescence, sex during adulthood, and sex and health. There is also an introduction and epilogue. Of necessity, there is some overlap with the earlier works. The editors review the original demographic categories (age, gender, marital status, education, race or ethnicity, and religious affiliation) and the relationship categories (short-term, long-term, cohabiting, married) and their impact on sexual issues. They reiterate that sexual choices, including number and type of partners and frequency and nature of sexual acts, are heavily influenced by social networks and mores. New data are presented on such topics as sexual dysfunction, sexual contact between children and adults, and circumcision. A comparison of public health policy toward sexually transmitted diseases in the United States and Britain is presented.

The interface between private sexual behavior and public policy is delineated in the section "Sex and Adolescence." Whether adolescents have sex before age 18, whether they use contraception consistently, and whether they decide to abort a pregnancy affects the rate of teens giving birth. There is a consensus that parenthood for early teens is undesirable but controversy over how to prevent it. Solutions vary from promotion of abstinence to ready access to contraceptives and abortion. This is one example among many presented about the difficulty of forming public policy in the United States, where values and views of what is considered appropriate sexual behavior vary widely and are maintained fervently.

In "Sex and Adulthood" the authors plumb the NHLS data for information about the sexual behavior of Americans. Persons are charted along five dimensions of behavior: number of sex partners, number of sex partners of the partner of the primary respondent, participation in venues that provide erotic stimulation (eg, nude beaches), frequency of masturbation, and frequency of partnered sex. These dimensions are then dichotomized (eg, yes or no answer to masturbation during the past year; one partner or more than one partner during the past year). Respondents are assigned to one of four sexual style categories, which differ for the men and the women. The categories are awkwardly named and not always self-explanatory (eg, venturesome cohabitor, moderate polygamist, autoerotic single), and some of the tables are overly large and cumbersome.

The findings are interesting, however, and make it worth wading through the material. For example, "enthusiastic polygamists," a category comprising 15% of male respondents, are "not yet married" or are divorced and are likely to have multiple partners, to have partners with multiple partners, to masturbate, and to seek multiple areas of stimulation (eg, erotic videos or phone calls and paid sex) but are also least likely to have intercourse more than once a week. The authors state that the core group critically implicated in the maintenance of sexually transmitted disease in the population at large comes from this class.

There are many findings of interest throughout the book. For example, the likelihood of a pregnant girl younger than 18 years opting to have an abortion increases dramatically with the educational level of her parents. Twelve percent of teens select this option if their parents did not finish high school, 48 percent if one parent graduated from high school, and 90 percent if one parent graduated from college. Men who have had same-sex experiences are more likely than others to experience low desire or premature ejaculation. Sexual dysfunction was found in 39% of men and 41% of women and, not surprisingly, interfered with the person's sense of well being and quality of life. A provocative finding was that consequences of adult-child sexual contact are not always disastrous. Some youngsters demonstrate remarkable resiliency following sexual abuse.

The multiauthorship of this volume makes it less cohesive and consistent in quality than the earlier volumes. Also, although the editors make a special effort to explain their statistical methodology, the explanation is not sufficiently clear to a statistical novice. These are minor issues, however. Sex, Love, and Health in America continues to explore sexual practices in an enlightening and medically necessary way. I recommend it highly to all those with an interest in human sexuality.

Approximately half of all US women and one fourth of US men dislike some aspect of their appearance, and more and more of them are turning to cosmetic surgery to correct the perceived defects. In Cosmetic Surgery, sociologist Deborah A. Sullivan explores this phenomenon and its implications for the commercialization of medicine in the United States.

Sullivan regards cosmetic surgery as a modern body custom. Like the binding of women's feet in ancient China or the black curves and spirals carved on Maori faces, these surgical changes "are an effort to achieve a desired identity and connection with a reference group." Certainly, as the author points out, our culture rewards those whose appearance most closely approximates the ideal with social, psychological, and economic benefits. However, this ideal is ever-changing, defined by a fickle media saturated with the latest desirable body images.

Although patient demand has fueled its growth, "there could be no cosmetic surgery unless some regular physicians in organized medicine were willing to offer it." Given that fact, Sullivan devotes much of the volume to scrutinizing the role of the medical profession in creating and promulgating indications for cosmetic surgery. She points out that "beauty has become a medical business." Cosmetic surgery differs from noncommercial medical care in that it electively alters healthy anatomical structures. It is a business enterprise aimed at generating a profit. But "medicine's mandate is to heal, not to beautify." Sullivan warns that cosmetic surgery might be the first step down a "slippery slope of compromised ethics and quality often found in for-profit commerce."

Several chapters explore how we arrived at this precarious position. Market forces include the increasing supply and specialization of physicians, the growth of managed care, and the rise of outpatient surgery. Improvement in overall health and safety in our country has decreased the need for catastrophic medical care and increased interest in medical and surgical treatments that maximize quality of life. Finally, and perhaps most significantly, the Federal Trade Commission's 1975 order that medicine could not restrict advertising made promotion a component of building a successful practice. Fearing just the sort of outcomes that Sullivan describes, the American Medical Association had long opposed physician advertising.

Additional chapters examine the rise of plastic surgery as a profession and the specialty's position on "the cutting edge of commercial medicine in America." In fact, Elizabeth Haiken's Venus Envy,^{1 - 2} much quoted here, provides a more complete and interesting look at the history of cosmetic surgery. Sullivan focuses on the foibles, sins, and, especially, the "sibling rivalry" of the American Society of Plastic and Reconstructive Surgeons and the American Academy of Facial Plastic and Reconstructive Surgery. Although I realize Sullivan's point is that such turf battles undermine physician authority, I suspect that most members of the organizations concerned are aware of these squabbles, and belaboring them is not particularly interesting to anyone else.

Perhaps it is a sociological matter, and perhaps the book's intended audience is sociologists. Patients contemplating cosmetic surgery would probably find it too academic and too little of it applicable to their decisions. Physicians are unlikely to encounter many new ideas and might find parts of the book offensive, as I did. Sullivan too often carries her valid concerns about the commercialization of medicine to extremes. Like cosmetic surgery, many currently accepted medical interventions are aimed at improving quality of life rather than saving it. In my field of gynecology, hormone replacement therapy would be a prime example, and one that I support.

In another section Sullivan states: "Sociologists and economists argue that professional gatekeeping such as accreditation of training programs, licensure, specialty certification, and advertising bans protect the interests of the professionals more than the interests of the public." Although she provides citations to support this claim, most physicians will find it arguable at best. Additionally, Sullivan identifies all materials published by the American Society of Plastic and Reconstructive Surgeons, including patient brochures discussing the benefits and risks of procedures, as promotional. She does not consider the issue of where promotion stops and patient education begins.

The final section of the book does include a thoughtful and incisive look at commercialism in the medical profession. In the end, Sullivan identifies both patients and physicians as victims, prospective patients being vulnerable to the power of marketing and physicians unable to overcome the dogma of deregulation. The villains, she proclaims, are our ingrained ideas about appearance and commercialism in medicine. She concludes, "As long as the government refuses to distinguish between the medical profession and other commercial trades under antitrust law, public oversight and regulations will be needed to protect patients." Physicians chafe at decreased autonomy, but it will help protect both patients and the profession's reputation.

If some people need to upgrade their cars or computers every five years or even sooner, why not do the same with their kidney books? This particular model, coming out some six years after the previous version, is now in its fourth edition. Formerly published in two volumes, it now consists of one volume but with the same number of pages (2000), bulky and heavy, so that those wishing to read it rather than decorate their libraries must undergo a certain amount of physical discomfort. They will, however, find the effort well worthwhile.

Officially the book has 109 chapters, but there are many more because some are subdivided into subchapters of related subjects. There are almost 400 contributors, often well-known experts in their own areas, drawn from the four corners of the earth and with one exception (from India) having their names spelled correctly. Most of the chapters have been updated, some have been replaced, but a few have been left unchanged. In each chapter the text is followed by a selected reading list—useful but largely drawn from pre-1997 publications.

Duplication, inevitable in a book that consists essentially of a collection of manuscripts by different authors, has been avoided to some extent by the senior authors writing many of the sections themselves. Yet diabetes insipidus is covered under "hypernatremia" and again under "polyuria"; the mechanism of acute renal failure is covered under "oliguria," "pigmenturia," and again under "acute renal failure." Discussions on parathyroid hormone and vitamin D metabolism reappear again and again. Hypertension, covered in an extensive section, is also offered as an appetizer under "The Cardinal Manifestations of Disease." Not surprisingly, doctors disagree: the etiology of dialysis dementia or encephalopathy, firmly attributed to aluminum intoxication in one chapter, is described a few pages later as controversial.

On the whole the book is well written. Some sections would score poorly on the Flesch readability scale, largely because of the complexity of the subject matter. Other parts are particularly well written, such as the introduction to the "dysnatremias," which I feel compelled to reproduce here:

Securely moored to the rigid confines of the cranial vault, the brain is vulnerable to forces that expand or contract its volume. Plasma hypotonicity from relative or absolute accumulation of water can passively inflate brain volume, causing fatal cerebral edema. By contrast, plasma hypertonicity from relative or absolute loss of water may shrink the brain, tearing it from its bony attachments and causing an equally tragic outcome.

Ensconced in the 2000 pages of a text in which brevity is not a virtue are three jewels, each capable of standing alone as a separate publication. First are the almost 500 pages on the diseases of the kidney and urinary tract—glomerular, interstitial, obstructive, metabolic, etc—well presented and with sensible treatment recommendations. A second remarkable section, perhaps the main strength of the book, covers the practical aspects of nephrology, clinical procedures and techniques (plasmapheresis, hemoperfusion, renal and bone biopsy, use of the ureteral catheter, lithotripsy), laboratory procedures (including a beautifully illustrated section on urinalysis and an excellent one on proteinuria), and almost 200 pages with great photographs on renal ultrasound, radiology, computed tomography, magnetic resonance imaging, and renal biopsies. Finally, there is an extensive review of basic knowledge about the kidney, its morphology and circulation, glomerular and tubular function, and chapters on erythropoietin, catecholamines, nitric oxide, adenosine, and other hormones or bioactive peptides.

Also well covered are hypertension and transplantation. The section on water and electrolytes, treated in the traditional manner, describes for each electrolyte its excretion, metabolism, and what happens when its blood levels are too high or too low. From a section on immunopathology, we learn that the innate immune system is 400 million years old and are presented with a dizzying description of the bindings, cleavages, and recombinations that characterize the complement cascade. Some of the discussions of toxic effects and metabolic or endocrine disturbances in uremia tend to be too drawn out, with authors perhaps devoting too much space to their own studies. Dialysis physicians will be interested to find out about leptin, an obesity factor present in higher levels in hemodialysis patients, and the more skeptical will heartily agree with the equivocal ratings given to zinc therapy in uremia. They will read about spontaneous tendon rupture; learn about osteocalcin, a noncollagenous protein under control of vitamin D that is elevated in osteitis fibrosa but lower in adynamic bone disease; enjoy an informative chapter on vascular access; but may find much of the hemodialysis section a bit dry—pages of uninterrupted text dominated by formulae, statistics, kinetics, and preoccupations with the so-called adequacy of dialysis.

There are actually few errors in the text, but on page 857 the nail patella syndrome is described as "a rare disease, affecting 221 million population"; the person who first described acquired cystic disease was Dunnill, not Durnhill (p 908); the legend on page 1981 mentions a new disease, "phrotic syndrome of the Finnish variety"; the legend 105.39 on the periodicity of collagen does not seem to have a corresponding figure (p 857); and Gittleman's syndrome, though mentioned several times, is not clearly differentiated from Bartter's. A delightful clinical presentation of idiopathic edema is followed by recommendations for extensive hospital admissions that would alarm most utilization review committees.

Who then should read this book? The specialist will find it useful to brush up on subjects not dealt with regularly in practice and to use as a reference. Fellows in training wishing to extend their field of study beyond their Palm Pilots will acquire by reading it some of the sophistication required of a seasoned specialist. And the general physician may be stimulated to rediscover the lost art of urinalysis, not be intimidated by a renal ultrasound or computed tomographic scan, and be better equipped to argue with the consultant on indications for renal biopsy. General physicians will also gain some insight into the many advances in basic science that will someday translate themselves into better treatments, especially for glomerular diseases, for which advances have been few and over which learned specialists continue to argue, with sometimes great passion, about modes of therapy, such as corticosteroids and cytotoxic drugs, that have now been available since almost the end of the second World War.