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The previous In the Clinic that addressed preoperative evaluation for noncardiac surgery was published in December 2016. This update reaffirms much of the information in the previous version and provides new information that has accumulated since then. The goal of preoperative assessment is to identify the risk for postoperative complications so health care teams can more fully understand how to implement strategies to mitigate risks before and after the operation.

Prevention and Initial Management of HIV Infection

Since July 2017, when In the Clinic last addressed management of HIV infection, there have been meaningful improvements in our ability to prevent HIV and to manage patients living with HIV. New approaches to preexposure prophylaxis and more effective treatments have made the elimination of HIV infection a feasible goal. The federal “Ending the HIV Epidemic” initiative aims at a 90% reduction in new HIV diagnoses by 2030. This article provides updated information on how clinicians should use these improvements to manage their patients who are at risk for HIV infection or are newly diagnosed with HIV.

Multiple Sclerosis

Many groundbreaking advances have occurred in the field of multiple sclerosis since this series last reviewed the disorder in 2014. The U.S. Food and Drug Administration has approved 7 new medications for relapsing–remitting multiple sclerosis and approved the first medication for primary progressive multiple sclerosis. The McDonald criteria for diagnosing multiple sclerosis were updated in 2017. New blood tests can now differentiate patients with multiple sclerosis from those with neuromyelitis optica spectrum disorder, and 3 new medications have been approved specifically for the latter disorder. Also, new medications for treating the symptoms of multiple sclerosis have been introduced.

Acute Pancreatitis

Acute pancreatitis is one of the most common reasons for gastroenterology-related hospitalization in the United States. With significant morbidity and subsequent mortality related to both the acute presentation and subsequent sequelae, prompt diagnosis and appropriate management are critical, especially in the first 24 hours of illness. It is also important to accurately recognize complications, such as pancreatic fluid collections and vascular events, and identify a definitive cause so that a strategy to prevent future attacks can be implemented.

Hearing Loss

Hearing loss is highly prevalent and may significantly affect how we age. Although the population is aging, relatively few adults receive treatment for hearing loss. Internists are a critical partner to audiologists and otolaryngologists in caring for the adult population with hearing loss. This review provides a primer on diagnosing and managing hearing loss.

Care of the Patient Using Cannabis

The past 2 decades have seen a revolution in legal access to cannabis, driven largely by activists and business interests. As a result, the population of cannabis users nationwide—especially daily users—has grown significantly. An estimated 4.5–7 million persons in the United States now meet criteria for cannabis use disorder annually. This article focuses on the effects of cannabis use, intoxication, and withdrawal while also reviewing the developmental pathways of cannabis use disorder as well as evidence-based pharmacologic and psychosocial treatments.

Hepatitis C Virus

Hepatitis C virus (HCV) is the most common bloodborne pathogen in the United States, chronically affecting approximately 2.4 million Americans, most of whom are unaware of the infection. Highly effective, well-tolerated therapies are now available with markedly simplified treatment algorithms. Eradication of HCV is a national goal. Increased efforts to extend access to treatment to populations that traditionally are difficult to treat, such as persons who inject drugs, are critical to achieving eradication. Given the magnitude of the disease burden, an increased role of primary care providers in screening, patient stratification, and treatment will be needed.

Hypothyroidism

Hypothyroidism is a common condition in which the thyroid gland provides insufficient amounts of thyroid hormone for the needs of peripheral tissues. The most common cause in adults is chronic lymphocytic thyroiditis (Hashimoto thyroiditis), but there are many other causes. Because most of the clinical features of hypothyroidism are nonspecific, the diagnosis requires laboratory testing. Serum thyroid-stimulating hormone (TSH) measurement is the best diagnostic test; an elevated TSH level almost always signals primary hypothyroidism. Serum free thyroxine levels may be below the reference range (overt hypothyroidism) or within the reference range (subclinical hypothyroidism). All patients with overt hypothyroidism should be treated, but those with subclinical hypothyroidism do not always benefit from treatment, especially elderly patients and those with baseline TSH levels below 10 mU/L. Oral L-thyroxine is the treatment of choice because of its well-demonstrated efficacy, safety, and ease of use. Therapy goals are symptom relief and maintenance of serum TSH levels within the reference range. Myxedema coma is a life-threatening form of decompensated hypothyroidism that must be treated with aggressive L-thyroxine replacement and other supportive measures in the inpatient setting.

Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a relatively new disease that has reached an incidence similar to that of Crohn disease and ulcerative colitis. With this increased presence, greater recognition is essential. This applies both to children with nonspecific but potentially debilitating symptoms and to adults who have spent years behaviorally compensating for narrow esophageal strictures. The pathogenesis of EoE is rapidly being unraveled and is based on initiation of a type II allergic response to specific food antigens, leading to dense esophageal eosinophilia, chronic inflammation, and esophageal fibrosis. With greater familiarity and understanding of EoE, treatments are evolving, including identification and avoidance of food antigens; broad applications of topical steroids; and, eventually, pathway-specific biologic therapy.

Hyperthyroidism

Thyrotoxicosis is a general term for excess circulating and tissue thyroid hormone levels, whereas hyperthyroidism specifically denotes disorders involving a hyperactive thyroid gland (Graves disease, toxic multinodular goiter, toxic adenoma). Diagnosis and determination of the cause rely on clinical evaluation, laboratory tests, and imaging studies. Hyperthyroidism is treated with antithyroid drugs, radioactive iodine ablation, or thyroidectomy. Other types of thyrotoxicosis are monitored and treated with β-blockers to control symptoms given that most of these conditions resolve spontaneously.

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