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Insulin Resistance Syndrome - Article
ABSTRACT: Insulin resistance can be linked to diabetes, hypertension, dyslipidemia, cardiovascular disease and other abnormalities. These abnormalities constitute the insulin resistance syndrome. Because resistance usually develops long before these diseases appear, identifying and treating insulin-resistant patients has potentially great preventive value. Insulin resistance should be suspected in patients with a history of diabetes in first-degree relatives; patients with a personal history of gestational diabetes, polycystic ovary syndrome or impaired glucose tolerance; and obese patients, particularly those with abdominal obesity. Present treatment consists of sensible lifestyle changes, including weight loss to attain healthy body weight, 30 minutes of accumulated moderate-intensity physical activity per day and increased dietary fiber intake. Pharmacotherapy is not currently recommended for patients with isolated insulin resistance.
Headaches in Children and Adolescents - Article
ABSTRACT: Headaches are common during childhood and become more common and increase in frequency during adolescence. The rational, cost-effective evaluation of children with headache begins with a careful history. The first step is to identify the temporal pattern of the headache--acute, acute-recurrent, chronic-progressive, chronic-nonprogressive, or mixed. The next step is a physical and neurologic examination focusing on the optic disc, eye movements, motor asymmetry, coordination, and reflexes. Neuroimaging is not routinely warranted in the evaluation of childhood headache and should be reserved for use in children with chronic-progressive patterns or abnormalities on neurologic examination. Once the headache diagnosis is established, management must be based on the frequency and severity of headache and the impact on the patient's lifestyle. Treatment of childhood migraine includes the intermittent use of oral analgesics and antiemetics and, occasionally, daily prophylactic agents. Often, the most important therapeutic intervention is confident reassurance about the absence of serious underlying neurologic disease.
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: Healthy eating and increased physical activity can prevent or delay diabetes and its complications. Techniques that facilitate adherence to these lifestyle changes can be adapted to primary care. Often, the patient's readiness to work toward change must be developed gradually. To prepare patients who are reluctant to change, it is effective to assess and address their conviction and confidence. Patients facing the long-term task of making lifestyle changes benefit from assistance in setting highly specific behavior-outcome goals and short-term behavior targets. Individualization is achieved by tailoring these goals and targets to the patient's preferences and progress, building the patient's confidence in small steps, and implementing more intensive interventions according to a stepped-care model. At each office visit, physician follow-up of the patient's self-monitored goals and targets enhances motivation and allows further customization of the plan. A coaching approach can be used to encourage positive choices, develop self-sufficiency, and assist the patient in identifying and overcoming barriers. More intensive intervention using a team approach maximizes adherence.
ABSTRACT: Impaired glucose tolerance and impaired fasting glucose form an intermediate stage in the natural history of diabetes mellitus. From 10 to 15 percent of adults in the United States have one of these conditions. Impaired glucose tolerance is defined as two-hour glucose levels of 140 to 199 mg per dL (7.8 to 11.0 mmol) on the 75-g oral glucose tolerance test, and impaired fasting glucose is defined as glucose levels of 100 to 125 mg per dL (5.6 to 6.9 mmol per L) in fasting patients. These glucose levels are above normal but below the level that is diagnostic for diabetes. Patients with impaired glucose tolerance or impaired fasting glucose have a significant risk of developing diabetes and thus are an important target group for primary prevention. Risk factors for diabetes include family history of diabetes, body mass index greater than 25 kg per m2, sedentary lifestyle, hypertension, dyslipidemia, history of gestational diabetes or large-for-gestational-age infant, and polycystic ovary syndrome. Blacks, Latin Americans, Native Americans, and Asian-Pacific Islanders also are at increased risk for diabetes. Patients at higher risk should be screened with a fasting plasma glucose level. When the diagnosis of impaired glucose tolerance or impaired fasting glucose is made, physicians should counsel patients to lose 5 to 7 percent of their body weight and engage in moderate physical activity for at least 150 minutes per week. Drug therapy with metformin or acarbose has been shown to delay or prevent the onset of diabetes. However, medications are not as effective as lifestyle changes, and it is not known if treatment with these drugs is cost effective in the management of impaired glucose tolerance.
The Patient with Daily Headaches - Article
ABSTRACT: The term 'chronic daily headache' (CDH) describes a variety of headache types, of which chronic migraine is the most common. Daily headaches often are disabling and may be challenging to diagnose and treat. Medication overuse, or drug rebound headache, is the most treatable cause of refractory daily headache. A pathologic underlying cause should be considered in patients with recent-onset daily headache, a change from a previous headache pattern, or associated neurologic or systemic symptoms. Treatment of CDH focuses on reduction of headache triggers and use of preventive medication, most commonly anti-depressants, antiepileptic drugs, and beta blockers. Medication overuse must be treated with discontinuation of symptomatic medicines, a transitional therapy, and long-term prophylaxis. Anxiety and depression are common in patients with CDH and should be identified and treated. Although the condition is challenging, appropriate treatment of patients with CDH can bring about significant improvement in the patient's quality-of-life.
Dysmenorrhea - Article
ABSTRACT: Dysmenorrhea is the leading cause of recurrent short-term school absence in adolescent girls and a common problem in women of reproductive age. Risk factors for dysmenorrhea include nulliparity, heavy menstrual flow, smoking, and depression. Empiric therapy can be initiated based on a typical history of painful menses and a negative physical examination. Nonsteroidal anti-inflammatory drugs are the initial therapy of choice in patients with presumptive primary dysmenorrhea. Oral contraceptives and depo-medroxyprogesterone acetate also may be considered. If pain relief is insufficient, prolonged-cycle oral contraceptives or intravaginal use of oral contraceptive pills can be considered. In women who do not desire hormonal contraception, there is some evidence of benefit with the use of topical heat; the Japanese herbal remedy toki-shakuyaku-san; thiamine, vitamin E, and fish oil supplements; a low-fat vegetarian diet; and acupressure. If dysmenorrhea remains uncontrolled with any of these approaches, pelvic ultrasonography should be performed and referral for laparoscopy should be considered to rule out secondary causes of dysmenorrhea. In patients with severe refractory primary dysmenorrhea, additional safe alternatives for women who want to conceive include transcutaneous electric nerve stimulation, acupuncture, nifedipine, and terbutaline. Otherwise, the use of danazol or leuprolide may be considered and, rarely, hysterectomy. The effectiveness of surgical interruption of the pelvic nerve pathways has not been established.
ABSTRACT: Antihypertensive therapy has been shown to reduce morbidity and mortality in older patients with elevated systolic or diastolic blood pressures. This benefit appears to persist in patients older than 80 years, but less than one third of older patients have adequate blood pressure control. Systolic blood pressure is the most important predictor of cardiovascular disease. Blood pressure measurement in older persons should include an evaluation for orthostatic hypotension. Low-dose thiazide diuretics remain first-line therapy for older patients. Beta blockers, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and calcium channel blockers are second-line medications that should be selected based on comorbidities and risk factors.
Treatment of Cholesterol Abnormalities - Article
ABSTRACT: Cardiovascular disease and its subset coronary heart disease are leading causes of morbidity and mortality in the United States and worldwide. In general, higher levels of low-density lipoprotein cholesterol are associated with an increased risk of coronary heart disease, myocardial infarction, and stroke. Reducing dietary fat can improve total cholesterol levels, but consequent reductions in cardiovascular outcomes are not well documented. The Mediterranean diet is the only dietary intervention associated with a reduction in all-cause mortality. Treatment with cholesterol-lowering medications decreases the rate of cardiovascular events, but a reduction in all-cause mortality with these agents has been found only in patients with pre-existing coronary heart disease. Drug treatment in patients with a history of heart disease and average-to-high cholesterol levels can decrease the risk for stroke. In patients with peripheral vascular disease, treatment of elevated cholesterol levels may slow disease progression.
ABSTRACT: Coronary heart disease remains a leading cause of mortality in the United States, with 84 percent of persons 65 years or older dying from this disease. Secondary preventive measures, including lifestyle modification and pharmacotherapy, are important for elderly patients because of the variable impacts on morbidity and mortality rates and quality of life. Participating in light to moderate activities significantly decreases mortality rates in elderly patients. Smoking cessation translates into a reduction in overall mortality and morbidity rates at least equal to that of other preventive measures such as aspirin or beta-blocker therapy. Recent studies on the effects of lowering low-density lipoprotein cholesterol levels to below 100 mg per dL have shown a substantial reduction in coronary heart disease mortality and nonfatal myocardial infarction rates, with a persistent effect in patients older than 75 years. Hypertension, manifesting mostly as isolated systolic blood pressure elevation, also should be treated aggressively. Conventional medical therapies for hypertension (e.g., diuretics, beta blockers) and newer agents (e.g., calcium channel blockers, angiotensin-converting enzyme inhibitors), together with sodium restriction, have had a positive effect on cardiovascular mortality and morbidity rates in older patients. With the increasing prevalence of obesity, insulin resistance, and type 2 diabetes, interventions targeting weight reduction and glucose control should be emphasized. Whereas weight-loss strategies are poorly defined in this population, the management of diabetes through dietary modification, exercise, and medications is similar across age groups. The target hemoglobin A1C level is less than 7 percent. Elderly patients are prone to depression and social isolation, and they are more likely to have a lower socioeconomic status than younger patients, which may negatively affect participation in rehabilitation programs and compliance with medical advice and therapy. Strategies aimed at these factors have shown variable results and remain ill-defined.