ITEMS IN AFP WITH MESH TERM:
ABSTRACT: Cardiovascular disease is the leading cause of death in women, as well as an important cause of disability, although many women and their physicians underestimate the risk. Exercise, hypertension treatment, smoking cessation and aspirin therapy are effective measures for the primary prevention of coronary artery disease in women. The roles of lipid-lowering agents and hormone replacement therapy in primary prevention are not well established. In secondary prevention, hormone replacement therapy has not been effective in lowering the risk of recurrent myocardial infarction, but several lipid-lowering agents have been shown to reduce this risk and to lower mortality rates in women with known coronary artery disease. Other secondary prevention measures, including aspirin, beta blockers, angiotensin-converting enzyme inhibitors, revascularization and rehabilitation, have proven benefits in women but are underused, especially in minority women. Family physicians should emphasize the use of proven treatments, with particular attention given to underserved populations.
ABSTRACT: Family physicians should take advantage of each contact with smokers to encourage and support smoking cessation. Once a patient is identified as a smoker, tools are available to assess readiness for change. Using motivational interviewing techniques, the physician can help the patient move from the precontemplation stage through the contemplation stage to the preparation stage, where plans are made for the initiation of nicotine replacement and/or bupropion therapy when indicated. Continued motivational techniques and support are needed in the action stage, when the patient stops smoking. Group or individual behavioral counseling can facilitate smoking cessation and improve quit rates. Combined use of behavioral and drug therapies can dramatically improve the patient's chance of quitting smoking. A plan should be in place for recycling the patient through the appropriate stages if relapse should occur.
Osteoporosis in Men - Article
ABSTRACT: Osteoporosis in men is now recognized as an increasingly important public health issue. About 30 percent of hip fractures occur in men, and one in eight men older than 50 years will have an osteoporotic fracture. Because of their greater peak bone mass, men usually present with hip, vertebral body, or distal wrist fractures 10 years later than women. Hip fractures in men, however, result in a 31 percent mortality rate at one year after fracture versus a rate of 17 percent in women. Major risk factors for osteoporosis in men are glucocorticoid use for longer than six months, osteopenia seen on plain radiographs, a history of nontraumatic fracture, hypogonadism, and advancing age. Bisphosphonates and teriparatide (recombinant parathyhroid hormone) have recently been approved for use in men and should be considered along with supplemental calcium and vitamin D. Increased awareness by physicians of risk factors for male osteoporosis--and early diagnosis and treatment--are needed to decrease the morbidity and mortality resulting from osteoporotic fractures.
Cholesterol Treatment Guidelines Update - Article
ABSTRACT: Hypercholesterolemia is one of the major contributors to atherosclerosis and coronary heart disease in our society. The National Cholesterol Education Program of the National Institutes of Health has created a set of guidelines that standardize the clinical assessment and management of hypercholesterolemia for practicing physicians and other professionals in the medical community. In May 2001, the National Cholesterol Education Program released its third set of guidelines, reflecting changes in cholesterol management since their previous report in 1993. In addition to modifying current strategies of risk assessment, the new guidelines stress the importance of an aggressive therapeutic approach in the management of hypercholesterolemia. The major risk factors that modify low-density lipoprotein goals include age, smoking status, hypertension, high-density lipoprotein levels, and family history. The concept of "CHD equivalent" is introduced-conditions requiring the same vigilance used in patients with coronary heart disease. Patients with diabetes and those with a 10-year cardiac event risk of 20 percent or greater are considered CHD equivalents. Once low-density lipoprotein cholesterol is at an accepted level, physicians are advised to address the metabolic syndrome and hypertriglyceridemia.
ABSTRACT: Chronic obstructive pulmonary disease is characterized by the gradual progression of irreversible airflow obstruction and increased inflammation in the airways and lung parenchyma that is generally distinguishable from the inflammation caused by asthma. Most chronic obstructive pulmonary disease is associated with smoking, but occupational exposure to irritants and air pollution also are important risk factors. Patients with chronic obstructive pulmonary disease typically present with coughing, sputum production, and dyspnea on exertion. However, none of these findings alone is diagnostic. The Global Initiative for Chronic Obstructive Lung Disease diagnostic criterion for chronic obstructive pulmonary disease is a forced expiratory volume in one second/forced vital capacity ratio of less than 70 percent of the predicted value. Severity is further stratified based on forced expiratory volume in one second and symptoms. Chest radiography may rule out alternative diagnoses and comorbid conditions. Selected patients should be tested for alpha1-antitrypsin deficiency. Arterial blood gas testing is recommended for patients presenting with signs of severe disease, right-sided heart failure, or significant hypoxemia. Chronic obstructive pulmonary disease also is a systemic disorder with weight loss and dysfunction of respiratory and skeletal muscles.
ABSTRACT: Tobacco use, primarily cigarette smoking, is the leading cause of preventable morbidity and mortality in the United States, and nearly one third of those who try a cigarette become addicted to nicotine. Family physicians, who see most of these patients in their offices every year, have an important opportunity to decrease smoking rates with office-based interventions. The U.S. Public Health Service recommends that primary care physicians use the five A's (Ask, Advise, Assess, Assist, and Arrange) model when treating patients with nicotine addiction. Physicians can improve screening and increase cessation rates by asking patients about tobacco use at every office visit. Behavior modification can improve long-term smoking cessation success; even brief (five minutes or less) advice on smoking cessation during an office visit can increase cessation rates. The effectiveness of nonpharmacologic treatments generally is lower; therefore, pharmacotherapy is recommended for smokers who are willing to attempt cessation, unless medical contraindications exist. The pharmacologic agents approved by the U.S. Food and Drug Administration for treatment of tobacco dependence include bupropion (a non-nicotine therapy) and nicotine replacement therapies in the form of a gum, patch, nasal spray, inhaler, and lozenge. These agents have similar long-term success rates.
Abdominal Aortic Aneurysm - Article
ABSTRACT: Most abdominal aortic aneurysms (AAAs) are asymptomatic, not detectable on physical examination, and silent until discovered during radiologic testing for other reasons. Tobacco use, hypertension, a family history of AAA, and male sex are clinical risk factors for the development of an aneurysm. Ultrasound, the preferred method of screening, is cost-effective in high-risk patients. Repair is indicated when the aneurysm becomes greater than 5.5 cm in diameter or grows more than 0.6 to 0.8 cm per year. Asymptomatic patients with an AAA should be medically optimized before repair, including institution of beta blockade. Symptomatic aneurysms present with back, abdominal, buttock, groin, testicular, or leg pain and require urgent surgical attention. Rupture of an AAA involves complete loss of aortic wall integrity and is a surgical emergency requiring immediate repair. The mortality rate approaches 90 percent if rupture occurs outside the hospital. Although open surgical repair has been performed safely, an endovascular approach is used in select patients if the aortic and iliac anatomy are amenable. Two large randomized controlled trials did not find any improvement in mortality rate or morbidity with this approach compared with conventional open surgical repair.
Reducing Tobacco Use in Adolescents - Article
ABSTRACT: After steadily decreasing since the late 1990s, adolescent smoking rates have stabilized at levels well above national goals. Experts recommend screening for tobacco use and exposure at every patient visit, although evidence of improved outcomes in adolescents is lacking. Counseling should be provided using the 5-A method (ask, advise, assess, assist, and arrange). All smokers should be offered smoking cessation assistance, including counseling, nicotine replacement therapy, bupropion therapy, or combination therapy. Pharmacotherapy of any kind doubles the likelihood of successful smoking cessation in adults; however, nicotine replacement therapy is the only pharmacologic intervention that has been extensively studied in children. Community interventions such as smoking bans and educational programs have been effective at reducing smoking rates in children and adolescents. Antismoking advertising and tobacco sales taxes also help deter new smokers and motivate current smokers to attempt to quit.
Assessing Nicotine Dependence - Article
ABSTRACT: Family physicians can assess the smoking behavior of their patients in a few minutes, using carefully chosen questions. The CAGE questionnaire for smoking (modified from the familiar CAGE questionnaire for alcoholism), the "four Cs" test and the FagerstrÃ¶m Test for Nicotine Dependence help make the diagnosis of nicotine dependence based on standard criteria. Additional questions can be used to determine the patient's readiness to change and the nature of the reinforcement the patient receives from smoking. These tools can assist family physicians in guiding patients to quit smoking-the single most important thing smokers can do to improve their health.
ABSTRACT: Menopause is the permanent cessation of menstruation resulting from the loss of ovarian and follicular activity. It usually occurs when women reach their early 50s. Vasomotor symptoms and vaginal dryness are frequently reported during menopause. Estrogen is the most effective treatment for management of hot flashes and night sweats. Local estrogen is preferred for vulvovaginal symptoms because of its excellent therapeutic response. Bone mineral density screening should be performed in all women older than 65 years, and should begin sooner in women with additional risk factors for osteoporotic fractures. Adequate intake of calcium and vitamin D should be encouraged for all postmenopausal women to reduce bone loss. Coronary artery disease is the leading cause of death in women. Postmenopausal women should be counseled regarding lifestyle modification, including smoking cessation and regular physical activity. All women should receive periodic measurement of blood pressure and lipids. Appropriate pharmacotherapy should be initiated when indicated. Women should receive breast cancer screening every one to two years beginning at age 40, as well as colorectal cancer screening beginning at age 50. Women younger than 65 years who are sexually active and have a cervix should receive routine cervical cancer screening with Papanicolaou smear. Recommended immunizations for menopausal women include an annual influenza vaccine, a tetanus and diphtheria toxoid booster every 10 years, and a one-time pneumococcal vaccine after age 65 years.