Obesity

PAWTUCKET, R.I. - Patients may not be getting the message about the heart risks associated with dyslipidemia when the message is delivered by-the-numbers, according to researchers here.

My 46-year-old patient had a fasting plasma glucose level of 115 mg/dL; a followupfasting plasma glucose level was 116 mg/dL.

A 52-year-old man complains of right knee pain that hasbeen increasing steadily for several weeks. Two years earlierhe underwent a total arthroplasty of the same knee to treatsevere osteoarthritis secondary to a meniscal injury. He hasno history of recent trauma or increased activity.

Diabetes is epidemic! The numbersare truly alarming. In 1997, official datashowed that 16 million people in theUnited States had diabetes. Approximately1 million had type 1 disease,and 10.4 million had type 2 disease; theremainder had undiagnosed diabetes.1If these numbers are projected outagainst an annual increase in diseaseprevalence of about 3.5%, it means thatby the year 2028, 50 million people willhave diabetes. However, the actual rateis closer to 7% each year. As such, approximately100 million Americans-roughly 1 of every 4-will have diabetesby 2028.

Abstract: Exercise intolerance is common in persons with chronic obstructive pulmonary disease and can result from multiple physiologic factors, including dynamic hyperinflation, gas exchange abnormalities, and pulmonary hypertension. In the initial assessment, keep in mind that many patients underestimate the degree of their impairment. The 6-minute walk test is very useful in assessing the degree of exercise intolerance; when more extensive assessment is indicated, cardiopulmonary exercise testing (CPET) is the gold standard. CPET is particularly useful for defining the underlying physiology of exercise limitation and may reveal other causes of dyspnea, such as myocardial ischemia or pulmonary hypertension. Strategies for improving exercise tolerance range from the use of bronchodilators and supplemental oxygen to participation in a pulmonary rehabilitation program. (J Respir Dis. 2006;27(5):208-218)

Abstract: The management options for persons with obstructive sleep apnea-hypopnea syndrome (OSAHS) include lifestyle changes, continuous positive airway pressure (CPAP), oral appliances, and surgery. Lifestyle modifications work best in persons with mild OSAHS and may include weight loss and cultivation of good sleep habits, such as not sleeping supine. Before initiating CPAP therapy, polysomnography is recommended to determine the best airway pressure for the patient. Although the benefits of CPAP have been well documented, compliance remains an issue; some difficulties may be alleviated through patient/partner education and close follow-up. Oral appliances, which work by mechanically enlarging or stabilizing the upper airway, are preferred by some patients; however, they are less effective than CPAP at reducing the apnea-hypopnea index. Surgical interventions to alleviate upper airway obstruction can be used in select patients. (J Respir Dis. 2006;27(5):222-227)

An examination of the evidence on the cardioprotective benefits associated with various intensity levels, types, and amounts of physical activity, as well as tips on a beneficial yet realistic exercise program.

What factors are causing the increased incidence of hypertension and cardiovascular mortality in African Americans, and what can be done to counteract them?

A 57-year-old woman presents with severe chest pain, and a frontal upright radiograph of the chest is obtained. What does this image reveal, and how will you arrive at a diagnosis?

A 62-year-old woman complained of right knee pain that had developed 1 year earlier after she had slipped on ice and fallen on the knee. Initial radiographs of the knee had shown mild degenerative changes. Treatment with NSAIDs for 10 months had failed to alleviate the pain.

A 79-year-old woman with a 37-year history of type 2 diabetes mellitus complains of head pain that began more thana month ago and is localized to the left frontotemporal region. She characterizes the pain as constant and burning, with minimalfluctuations in intensity. The pain does not increase with any particular activity but is quite disabling; it has causedemotional lability and insomnia. She denies nausea, visual disturbances, weakness of the extremities, dizziness, or tinnitus.Her appetite is depressed; she has experienced some weight loss.

The line on the gums of this 30-year-old man indicates lead poisoning. The patient had been employed for 8 months at a lead smelting plant in which no occupational safety precautions had been enforced. He was admitted to the hospital with the classic symptoms and signs of lead poisoning--pain in the nape of the neck that radiated down the spine, posterior thighs, and calves to the plantar aspect of the feet; colicky panabdominal pain; anorexia; weight loss; nausea; vomiting; constipation; bone and muscle tenderness; hyperesthesia of all extremities; insomnia; irritability; generalized weakness; malaise; and dizziness.

Have any specific genes been identified for type 1 or type 2 diabetes? If so, howmany genes are involved?

The authors of the Women’s HealthInitiative (WHI) study involving50,000 postmenopausal women concluded thata low-fat diet (goal: 20% of total calories) had no significant effect on the incidence of breast cancer, coloncancer, or heart disease. What should we be telling our patients?

A 52-year-old woman was admitted tothe hospital with progressive shortnessof breath of 2 days’ duration. Bronchialasthma had been diagnosed 6 monthsearlier; inhaled corticosteroids, bronchodilators,and leukotriene antagonistswere prescribed. Despite aggressivetreatment, the patient’s dyspneaand wheezing worsened.

Q:What is the best screening test for suspectedrenal artery stenosis?

A 66-year-old man presented with weight loss for 2 months, loss of appetite for several weeks, and abnormal chest radiographic findings. He denied chest pain, cough, fever, chills, shortness of breath, and chest trauma. He was an active smoker, with a 50-pack-year history of smok- ing, and a cocaine and alcohol abuser. His history included treatment of hypertension for 10 years and treatment of pulmonary tuberculosis 14 years previously.

Abstract: Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a common, yet often overlooked, form of symptomatic sleep-disordered breathing. OSAHS is a cause for concern for several reasons, one of which is its association with cardiovascular disease. Risk factors include obesity, hypertension, and upper airway malformations. Diagnostic clues include habitual snoring, witnessed apneas, choking arousals, excessive daytime sleepiness, and large neck circumference. Polysomnography is the definitive diagnostic test; it pro- vides objective documentation of apnea and hypopnea. Since OSAHS may contribute to adverse postsurgical events, consideration of this syndrome should be part of the preoperative assessment of patients. (J Respir Dis. 2006;27(4):144-152)

Abstract: Multidrug-resistant tuberculosis is defined as tuberculosis caused by strains that have documented in vitro resistance to isoniazid and rifampin. Treatment involves a regimen consisting of at least 4 or 5 drugs to which the infecting strain has documented susceptibility. These agents may include ethambutol, pyrazinamide, streptomycin, a fluoroquinolone, ethionamide, prothionamide, cycloserine, and para-aminosalicylic acid. In addition, an injectable agent, such as kanamycin, amikacin, or capreomycin, should be used until negative sputum cultures have been documented for at least 6 months. If the patient has severe parenchymal damage, high-grade resistance, or clinically advanced disease, also consider clofazimine, amoxicillin/clavulanate, or clarithromycin, although there is little evidence supporting their efficacy in this setting. Routine monitoring includes monthly sputum smear and culture testing, monthly assessment of renal function and electrolyte levels, and liver function tests every 3 to 6 months. (J Respir Dis. 2006;27(4):172-182)

In this article, I review several interventions that have been shown or are postulated to reduce breast cancer risk in women with no history of the disease; these include chemoprevention, physical activity, weight control, diet, alcohol use, and avoidance of specific carcinogens.

Rheumatoid arthritis (RA) affects 1% ofadults during their most productiveyears and can result in significant disability.The goals of therapy are to reducepain, limit joint destruction, andpreserve function.

A 54-year-old woman presents with severe, throbbingpain in her right shoulder that began 3 daysearlier. She has no history of trauma or of problems withthis shoulder. She denies shortness of breath, fever,chills, and rash.

A 35-year-old woman has been losing weight and has hadworsening abdominal pain and fullness for the past 2 months.She denies nausea, vomiting, and fever. Medical history issignificant only for asthma.

You routinely order laboratory screeningpanels, including serum liver enzymemeasurements, for nearly everypatient who has a complete physicalexamination or who is seen for any ofa host of other complaints. If you findabnormal liver enzyme levels, your familiaritywith the common causes andthe settings in which they occur mayenable you to avoid costly diagnosticstudies or biopsy.

Chronic headache that worsened when she bent forward and episodes of usually unilateral vision loss sent a 34-year-old woman for medical consultation. The vision loss occasionally occurred in both eyes simultaneously.

Excess weight increases the risk of having a heart attack, stroke, high blood pressure, arthritis, diabetes, depression, fatigue, and certain types of cancer. Losing weight and keeping it off are very difficult for most persons who are overweight. Here are some suggestions to help you lose pounds and keep your weight down.

In this article, we review the factors that contribute to obesity. We then describe effective approaches to weight control, including exercise, dietary modification, drug treatment, and bariatric surgery.

Monday morning your nurse hands you charts for 4 new patients. Each patient is a woman with widespread body pain, stiffness, and fatigue. All have already been evaluated by another physician and were advised that they should reduce stress and practice distraction techniques. They are in your office today seeking a second opinion.

Weight gain is a well-known risk factor for the development of sleep-disordered breathing (SDB), and there is some evidence that weight loss can lead to improvement in SDB. Data from the Sleep Heart Health Study indicate that even modest changes in weight can be significant, especially in men.

For 3 years, a 23-year-old man has had this asymptomatic, 0.75-cm, polypoid lesion on his left wrist.