Obesity Medicine

ABSTRACT: Early treatment with disease-modifying anti-rheumatic drugs (DMARDs)--alone or in combination-- can prevent joint damage and minimize disability. Until recently, the DMARDs used predominantly in patients with rheumatoid arthritis had been methotrexate, sulfasalazine, and hydoxychloroquine. Older DMARDs such as gold, d-penicillamine, and azathioprine have fallen out of favor because of their long- term toxicities or modest benefit. Six newer DMARDs--leflunomide, etanercept, infliximab, adalimumab, rituximab, and anakinra--have greatly expanded the current treatment options.

32-year-old man presents with a 4-day history of fever (temperature as high as 38.8 C to 39.4 C with severe rigors, chills, and profuse night sweats; generalized myalgias, including dull, aching headache; and dry cough.

The authors describe a rare cause of diffuse thoracic lymphadenopathy--Cogan syndrome. This case was remarkable for the temporal development of extensive lymphadenopathy independent of other hallmark symptoms and signs of this syndrome. In the appropriate clinical setting, Cogan syndrome should be considered in the differential diagnosis of thoracic lymphadenopathy.

During a routine annual checkup, a 5-ft 8-in, 94.5-kg (210-lb) 13-year-old girl was noted to have a hyperpigmented "dirty" lesion on the back of her neck. The girl's parents were also obese. Her mother had type 2 diabetes mellitus.

For several weeks, an 82-year-old woman had experienced blurred vision while reading. She was unable to localize the problem to either eye.

One third of all American adults (more than 70 million people) are currently on a diet. More than half of all adults have attempted dieting at some point--often more than once.

Abstract: Although excessive daytime sleepiness is most often simply the result of inadequate sleep, other causes must be considered as well. Common causes of daytime sleepiness include obstructive sleep apnea/hypopnea syndrome (OSAHS) and medication side effects. The differential diagnosis also includes narcolepsy and restless legs syndrome (RLS). In many cases, the answers to a few simple questions can provide the necessary clues to the diagnosis. Loud snoring is associated with OSAHS, while sudden muscle weakness triggered by intense emotion is consistent with narcolepsy. Referral for sleep evaluation is indicated to evaluate for OSAHS, narcolepsy, RLS, and idiopathic hypersomnia. Methods of measuring daytime sleepiness include the Multiple Sleep Latency Test and the Epworth Sleepiness Scale. (J Respir Dis. 2005;26(6):253-259)

Abstract: A number of scoring systems can be used to help predict difficult intubations. The Mallampati system, for example, can be useful in assessing patients before elective surgery, but it is less practical in emergent situations. Clinical features that suggest a potentially problematic airway include relatively long upper incisors, prominent overbite, narrow palate, edematous mandibular space, thick neck, and limited flexion of the neck. The most effective and rapid way of securing definitive airway management remains direct laryngoscopy with placement of an endotracheal tube (ETT). The ETT/stylet assembly of the light wand is best used when the patient can be successfully ventilated with a bag-valve mask device between intubation attempts. One of the most critical components of airway management is confirming that the ETT has been successfully placed in the trachea. (J Respir Dis. 2005;26(6):268-276)

A morbidly obese 63-year-old woman with type 2 diabetes mellitus and hypertension presented with postmenopausal vaginal bleeding. A uterine biopsy revealed papillary mucinous adenocarcinoma, and biopsy of a breast mass detected during the examination also showed adenocarcinoma. The patient underwent irradiation of the pelvis and breast.

Menstrual disorders are one of the most common complaints of women seen in primary care. Abnormal uterine bleeding (AUB) is a broad term that encompasses bleeding at abnormal or unexpected times or excessive flow at times of expected menses.

A 65-year-old woman with well-controlled hypertension comes in for a routine checkup. During the past 10 years, she has gained 25 lb and lost 1.5 inches in height.

As recommended by the authors, I commonly order a fasting lipid profile and measurements of glucose and insulin levels in children at risk for type 2 diabetes. One area of management that remains confusing is the approach to take with children who have an elevated fasting insulin level but otherwise normal laboratory results.

Several popular diets, such as the South Beach Diet and Sugar Busters, are based on the glycemic index; however, many patients are confused about its significance.

Primary care physicians are usually the first to see patients with joint pain; consequently they represent the "front line" of RA care. This fact-coupled with the projection that the number of rheumatologists is expected to decline by 20% during the next 2 to 3 decades-underscores the pivotal role that primary care clinicians are now expected to play in the early diagnosis of RA.

A 38-year-old man presented to the emergency department (ED) with a 2-week history of worsening shortness of breath and dry cough. He also complained of anorexia, a 14-kg (30-lb) weight loss over 3 months, pleuritic chest pain, and night sweats.

How important is control of obesity in the treatment of hypertension?

What steps can older patients take now to improve their health and quality of life and maintain their independence?

A 45-year-old Asian man presents with a 3-week history of weight loss, poor appetite, fatigue, intermittent sweats, and a nonproductive cough. The patient, a recent immigrant, denies previous illness.

Cardiovascular disease is the chief cause of death among women. Nevertheless, in a recent survey of women, only 13% responded that their own greatest health threat was heart disease.

Now that the role of inflammation in the pathogenesis of cardiovascular disease has been recognized, biomarkers of inflammation have become the subject of intense research interest. Once considered a novel cardiovascular risk factor, the inflammatory biomarker C-reactive protein (CRP) is currently believed to improve global risk prediction in patients not previously deemed at high risk.

ABSTRACT: Education can help improve compliance with inhaled corticosteroid therapy or correct faulty metered-dose inhaler (MDI) technique. Options for patients with poor MDI technique include use of a spacer or an alternative device, such as a nebulizer or a dry powder inhaler. If therapy is ineffective, consider alternative conditions that mimic asthma, especially vocal cord dysfunction and upper airway obstruction. Treatment of comorbid conditions, such as gastroesophageal reflux disease or rhinosinusitis, may improve control. In refractory asthma, it is crucial to identify allergic triggers and reduce exposure to allergens. If another medication needs to be added to the inhaled corticosteroid, consider a long- acting b-agonist, leukotriene modifier, or the recombinant monoclonal anti-IgE antibody omalizumab.

Exercise is a safe and effective therapy for patients with osteoarthritis or rheumatoid arthritis. It can reduce pain, increase flexibility and strength, and prevent deconditioning. To help motivate patients to initiate and adhere to an exercise program, educate them about these benefits, encourage them to set specific goals, recommend that they commit to a routine for at least 6 to 8 weeks (the minimum time needed to appreciate significant results), and warn them not to be discouraged by initial soreness. An exercise program for a patient with arthritis should include stretching (to improve joint flexibility), strengthening (to prevent deconditioning of the muscles that keep the joints stable), and aerobic exercise (to enhance overall fitness). Isotonic strengthening exercise is particularly important because it can reverse muscle wasting. Recommend that patients exercise for 30 minutes a day, 5 days a week. Water exercise is especially beneficial.

A 58-year-old man with type 2 diabetes mellitus and hypertension was hospitalized with acute diarrhea characterized by several brown, liquid depositions per day. He also complained of lower abdominal pain and bloating and a 10-lb weight loss in the past 2 months. He denied fever or chills, use of corticosteroids, and travel outside the United States.

A 40-year-old man presented with a 1-year history of progressively worsening dysphagia. He reported difficulty in swallowing both solids and liquids and had experienced mild weight loss during the past few months. He had no history of gastroesophageal reflux.

For 4 weeks, a 23-year-old runner has had a painful burning sensation about 1 inch above andlateral to the left knee cap. Occasionally, the pain radiates to her hip and 1 inch down the lateralside of her leg.

For years, a 60-year-old obese woman with type 2 diabetes mellitus had thiswarty lesion on the outer tarsal plate in the middle of the left upper eyelid.It was asymptomatic. She also had a few asymptomatic epidermal inclusioncysts on the upper and lower eyelids.

Age-related maculardegeneration(AMD) isthe leadingcause of untreatedvision loss amongpersons 65 years andolder and accounts for 45%of all visual disability inthe United States.1 Thiscondition usually has significantadverse effects onquality of life.2 As the USpopulation continues toage, the number of Americanswith AMD is expectedto increase.3

ABSTRACT: A host of evidence supports the treatment of high levels of low-density lipoprotein (LDL) cholesterol with HMG-CoA reductase inhibitors (statins), which are effective in both primary and secondary prevention of coronary heart disease (CHD). Studies have shown that statins prevent first cardiac events in otherwise healthy persons with elevated LDL cholesterol and low high-density lipoprotein cholesterol levels. Statins are also associated with a reduction in cardiac death, stroke, hospitalization, and the need for revascularization in patients with established CHD and hyperlipidemia. Secondary prevention trials of statin therapy that included persons aged 65 to 75 years found significant risk reduction in this age group. Among the concerns associated with statin treatment are lack of proper titration, failure to achieve LDL target goals, and underuse in patients with established CHD.

Until recently, celiac diseasewas considered a rare disorder.However, new evidencesuggests that about1% of Americans are affected.As serologic tests that detect autoantigensinvolved in celiac diseasebecome more widely used, morecases will likely be identified.1

ABSTRACT: First steps in the treatment of irritable bowel syndrome (IBS) are dietary modification, smoking cessation, and other lifestyle changes. Treatment of mild symptoms includes increased soluble dietary fiber and osmotic laxatives for constipation, antispasmodics for cramping, and over-the-counter antidiarrheals. For moderate disease, serotonergic agents work primarily in the intestine to relieve the global symptoms of IBS. Alosetron decreases gut motility and visceral sensitivity in women with chronic, severe diarrhea-predominant IBS who have not responded to conventional therapies. Tegaserod relieves pain, bloating, and constipation in women with constipation-predominant IBS. Psychotherapy, hypnotherapy, biofeedback, and other nonpharmacologic modalities may also be helpful for patients with IBS. Antidepressants are reserved for refractory symptoms; they can be combined with other modalities if needed.