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Am Fam Physician. 1999;59(8):2355

Cataract Surgery

(Great Britain—The Practitioner, December 1998, p. 836.) The prevalence of cataracts rises exponentially with age and is accelerated in patients with diabetes mellitus. Patients usually complain of decreased vision, especially in bright environments, but many cases are diagnosed during routine eye examination. It is important to assess patients for co-existing or alternative causes of vision deterioration. Many patients have dual pathology, especially macular degeneration plus cataract, but these patients may benefit considerably from cataract surgery. Patients with myopia and hypermetropia report greatest benefit from cataract surgery because corrective lenses can be inserted, allowing them to abandon eyeglasses. Most cataract surgery is now performed under local anesthesia and therefore can be tolerated by many patients, but severe respiratory disease and severe, uncontrolled hypertension remain relative contraindications to surgery. The advantages and disadvantages of the proposed surgery should be discussed in detail with patients and family members. Most cataract surgery currently uses phacoemulsification techniques, which can be combined with drainage procedures for glaucoma. Patients may require explanation of the various techniques now available, as their perceptions of cataract surgery may be based on older procedures.

Coronary Artery Disease in Women

(Canada—Canadian Family Physician, December 1998, p. 2709.) Coronary artery disease (CAD) is now the leading cause of mortality among women in developed countries. The incidence in women remains lower than that in men until the sixth and seventh decades of life, but for many reasons outcomes are less favorable in women than in men. The major risk factors for CAD in women are diabetes and uncompensated postmenopausal status, with hypertension, smoking and lipid abnormalities as intermediate risks and sedentary lifestyle, obesity, age and family history as relatively minor risk factors. Women are more likely than men to have silent myocardial infarctions or to present with atypical symptoms such as nonexertional chest pain, nausea, presyncope, dyspnea or pain in unusual locations. Conventional investigations, particularly exercise stress testing, are less reliable in women than in men. Some of the reasons for poorer outcomes of CAD therapy in women may be greater age and comorbidity. Although trials have often included relatively few women, risk factor reduction, aspirin therapy, cardiac rehabilitation and use of beta blockers and angiotensin-converting enzyme inhibitors following myocardial infarction have all proved beneficial. Women have significantly greater rates of complications and mortality with revascularization procedures than men but may have a comparable long-term prognosis following successful surgery.

Insomnia in Elderly Persons

(New Zealand—New Zealand Family Physician, December 1998, p. 11.) Community surveys indicate that at least one third of elderly persons report sleep disturbance. Insomnia in the elderly is associated with female sex, depression, living alone, use of psychotropic drugs, and limited activity. Elderly persons have a reduced arousal threshold for noise, increased difficulty initiating sleep, earlier waking times, decreased deep sleep (stages 3 and 4) and rapid-eye-movement (REM) sleep and more nocturnal wakenings than do younger persons. The elderly are more likely to be sleepy through the day and to take daytime naps, so their total 24-hour sleep time may be equal to that of younger persons. In addition to disturbances of circadian patterns, insomnia may be caused by psychiatric disorders, alcohol or drug withdrawal, several medical illnesses and various medications. Management of insomnia in the elderly should target the most likely cause, usually identified by history and information from a sleep diary. General advice on good sleep hygiene includes regular sleeping times, comfortable bedroom and bedding, avoidance of stimulants close to bedtime, and moderate exercise during the day (but not close to bedtime). Hypnotic medications should be used only as short-term adjuncts to education and lifestyle modification. The role of melatonin and tryptophan is still unclear.

Hyperostosis Frontalis Interna

(Hong Kong—Hong Kong Practitioner, November 1998, p. 636.) Benign hyperostosis of the inner table of the frontal bone can produce an alarming appearance on skull radiographs. Hyperostosis frontalis interna results in mild to moderate symmetric thickening of the inner table of the frontal bone, producing a wavy or “choppy sea” appearance on radiographs. The midline and occipital areas are spared. The condition is asymptomatic and benign, and usually occurs in women over 40 years of age. The differential diagnosis includes Paget's disease, sclerosing osteomyelitis and osteosclerotic metastases to the skull.

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