June 24th 2024
ADA 2024. Adults with OSA and obesity receiving tirzepatide had improvements in sleep apnea severity and systolic blood pressure compared to placebo.
Diving Medicine: Questions Physicians Often Ask, Part 2
July 1st 2004Most sport-diving problems are mild and self-limited; however, serious or life-threatening situations can arise. In a previous article (CONSULTANT, June 2004, page 961), we addressed fitness and safety issues. In this article, we review the principal medical problems associated with sport diving.
Matters of the Heart: Aortitis
May 2nd 2004An obese 61-year-old man who hadchronic obstructive pulmonary diseaseand sleep apnea heard a “pop”in his stomach while lifting a heavyweight; severe abdominal pain followed.He was short of breath thenext morning, and his physician empiricallyprescribed cephalexin.
Man With Incapacitating Daily Headaches
April 2nd 2004A 39-year-old man complains of severe daily headaches that he describes as throbbing and "burning," with a sensationof pressure. He rates the severity of his pain as 8 to 10 on a 10-point visual analog scale (VAS) in which 10 isthe most severe. The mean duration of the headaches is 12 hours, and the mean frequency is 5 days per week. Betweenthe episodes of severe headache, he has constant "minor" headaches that are not as severe (mean severity, 3 to 5 on a10-point VAS). Within the past 5 months, he has never been totally free of headache.
The 10 Most Common Prescribing Errors: Tips on Avoiding the Pitfalls
February 1st 2004Numerous factors contribute to the medication errors that kill up to 98,000 patients each year. Unnecessarily high dosages can result in increased side effects with only a small therapeutic benefit, especially in elderly patients. Lack of patient information-such as a history of allergies or adverse drug reactions-is another cause of error and injury. Communication failures include the use of ambiguous abbreviations, misinterpretation of verbal orders, and lack of timely response to a patient's medication-related symptoms. Dosing errors are common in children because of variability in dosage expressions in drug references. Remedies for prescribing errors are described in detail here.
Fibromyalgia Syndrome: Can It Be Treated?
February 1st 2004Treatment of fibromyalgia syndrome (FMS) is a challenge. However, most patients benefit from appropriate management. Essential to treatment are a physician's positive and empathetic attitude, continuous psychological support, patient education, patience, and a willingness to guide patients to do their part in management. Other important aspects involve addressing aggravating factors (eg, poor sleep, physical deconditioning, emotional distress) and employing various nonpharmacologic modalities (eg, regular physical exercise) and pharmacologic therapies. Drug treatment includes use of tricyclic medications alone or in combination with a selective serotonin reuptake inhibitor, and other centrally acting medications. Tender point injection is useful. It is important to individualize treatment. Management of FMS is both a science and an art.
Chronic Obstructive Pulmonary Disease: New Treatments Against an Old Foe
January 1st 2004The key factor in reducing morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD) continues to be smoking cessation. Newer formulations of nicotine replacement therapy-a nasal spray and an inhaler-provide rapid delivery of nicotine and may be appropriate for highly dependent smokers. Bupropion has been shown to improve smoking cessation rates, either when used alone or with a nicotine patch. Both the influenza and pneumococcal vaccines are recommended to reduce the morbidity and mortality associated with respiratory infections in patients with COPD.
How to Handle Chronic Cough in Kids:
December 1st 2003ABSTRACT: A cough is considered chronic when it persists for 3 or more weeks. Typically, chronic cough is a lingering manifestation of a viral upper respiratory tract infection; other, more serious causes-such as asthma, sinusitis, or gastro- esophageal reflux-must also be considered. Look to the history for diagnostic clues and order a chest film, which may point to pneumonia, hyperinflation, atelectasis, or cardiac or pulmonary abnormality. Diagnostic test methods will depend, in part, on the child's age; for example, the American Academy of Pediatrics recommends against imaging of the sinuses in children 6 years or younger. Pulmonary function tests can be useful in diagnosing asthma if the child is able to cooperate. Consider ordering a barium swallow for a very young child whose cough may be the result of a vascular anomaly. A pH probe study can help you determine whether cough is secondary to gastroesophageal reflux. Treatment is directed at the underlying cause.
Chronic Pain Control: What's Adequate- and Appropriate?
November 1st 2003ABSTRACT: The results of diagnostic tests do not correlate well with the presence and severity of pain. To avoid missing a serious underlying condition, look for "red flags," such as unexplained weight loss or acute bladder or bowel function changes in a patient with low back pain. Nonopioid medications can be more effective than opioids for certain types of pain (for example, antidepressants or anticonvulsants for neuropathic pain). When NSAIDs are indicated, cyclooxygenase-2 inhibitors are better choices for patients who are at risk for GI problems or who are receiving anticoagulants. However, if nonspecific NSAIDs are not contraindicated, consider using these far less expensive agents. The tricyclic antidepressants are more effective as analgesics than selective serotonin reuptake inhibitors. When opioids are indicated, start with less potent agents (tramadol, codeine, oxycodone, hydrocodone) and then progress to stronger ones (hydromorphone, fentanyl, methadone, morphine) if needed.
Obese Young Girl With Acanthosis Nigricans and Vaginal Yeast Infection
September 1st 2003A 12-year-old African American girl comes to youroffice for a well-child checkup. She is tall for herage (height above the 95th percentile) and obese(body mass index [BMI] above the 95th percentile).Physical examination reveals acanthosisnigricans on her neck, axilla, and upper abdominalregion (Figure) and a vaginal yeast infection.Routine urinalysis reveals a glucose level ofgreater than 1000 mg/dL, with negative proteinand ketones. A random blood glucose test, obtainedbecause of the glucosuria, is 249 mg/dL.
Fibromyalgia: Making a Firm Diagnosis, Understanding Its Pathophysiology
September 1st 2003ABSTRACT: Fibromyalgia syndrome (FMS) is a common condition that causes chronic pain and disability. It should be diagnosed by its own clinical characteristics of widespread musculoskeletal pain and multiple tender points. American College of Rheumatology criteria guidelines are most helpful in diagnosing FMS. The major symptoms are pain, stiffness, fatigue, poor sleep, and those of other associated conditions, for example, irritable bowel syndrome, headaches, restless legs syndrome, chronic fatigue syndrome, and depression. The pathophysiology of FMS is thought to involve central sensitization and neuroendocrine aberrations, triggered or aggravated by genetic predisposition; trauma; psychosocial distress; sleep deprivation; and peripheral nociception.
Smoking Cessation: How to Make Pharmacotherapy Work
May 1st 2003ABSTRACT: Effective smoking cessation strategies typically encompass the use of some pharmacotherapy with counseling by physicians. Give the Fagerstrom test to patients who want to quit smoking to determine their degree of nicotine dependence. For low-nicotine-dependent smokers, the use of 1 smoking cessation product for a short period has proved successful; for high-dependence smokers, a combination of products, such as nicotine gum and a nicotine patch, can be used. Other available smoking cessation products are the nicotine nasal spray, the nicotine inhaler, and sustained-release bupropion. Increasing the dose or duration of nicotine gum and patch has improved abstinence rates among high- dependence smokers. Quit rates have also been shown to increase with the dose of bupropion.
When Are OTC Analgesics Appropriate for Acute Migraine?
February 1st 2003A 34-year-old woman complains of headaches that interfere with work. Her first headache episode, approximately 6 yearsearlier, was relatively mild. Initially, she experienced attacks only once every 3 to 4 months and managed them effectivelywith over-the-counter (OTC) agents. However, in the last 6 months the attacks have become more frequent-they occur atleast twice a month-and are so severe that she misses work.
Osteoarthritis: Practical Nondrug Steps to Successful Therapy
January 1st 2003The diagnosis of osteoarthritis (OA) is primarily clinical. Key historical clues to idiopathic OA include patient age greater than 45 years, joint pain that increases with activity and is relieved with rest, morning stiffness of 30 minutes duration or less, and involvement of one or more of the following: hips, knees, cervical or lumbar spine, basilar thumb joints, interphalangeal joints of the hands, midfoot joints, and first metatarsophalangeal joints.
Osteoarthritis: How to Make Optimal Use of Medications
January 1st 2003ABSTRACT: Topical agents can provide temporary relief from osteoarthritis symptoms with little or no risk. Acetaminophen is first-line oral therapy. Be alert for risk factors for NSAID-induced GI toxicity, such as concurrent use of prescription and OTC agents. Tramadol, narcotic analgesics, muscle relaxants, and antidepressants are options when NSAIDs are ineffective or contraindicated. Intra-articular injections of corticosteroids or hyaluronan are appropriate for patients who have a single joint exacerbation. Total knee and total hip arthroplasty are considered the most effective surgical interventions.
Acute Coronary Syndromes: Treatment With Fibrinolytic and Antiplatelet Agents
December 1st 2002ABSTRACT: The main therapeutic goals for patients who have an acute coronary syndrome are to reestablish normal epicardial flow and to increase distal myocardial perfusion. Fibrinolytic treatment with tissue plasminogen activator within 70 minutes of the onset of symptoms dramatically reduces the mortality rate from myocardial infarction. Other fibrinolytic agents include reteplase, which is given as a double bolus, and tenecteplase, which is given as a single bolus. In most hospitals, fibrinolytic therapy is more readily available than percutaneous transluminal coronary angioplasty (PTCA); however, PTCA may be the preferred approach if it is available within an hour and a half. Antiplatelet drugs, such as glycoprotein IIb/IIIa receptor antagonists, are used to improve distal myocardial perfusion. If follow-up coronary angiography is not available to assess whether epicardial blood flow and distal myocardial perfusion have been restored, a 12-lead ECG can provide valuable information. The resolution of ST-segment abnormalities is a marker for improved perfusion.