Obesity Medicine

The authors describe a woman who presented with severe pulmonary hypertension. A cardiopulmonary cause was initially sought, but thyrotoxicosis was the underlying cause.

Diabetic nephropathy, the leading cause of end-stage renal disease (ESRD) in the United States, affects 20% to 30% of patients with diabetes. Early diagnosis and aggressive treatment may delay the progression of kidney disease.

ABSTRACT: The key features of polycystic ovary syndrome (PCOS) are menstrual bleeding disturbances caused by chronic oligoovulation or anovulation and clinical or biochemical hyperandrogenism. The finding of polycystic ovaries on ultrasonography alone has limited predictive value. Obesity often coexists with PCOS and can exacerbate metabolic disturbances, particularly insulin resistance, but it is not a diagnostic finding. Laboratory results can rule out other conditions in the differential, such as an androgen- producing neoplasm, hypothyroidism, and late-onset congenital adrenal hyperplasia.

The secret to weight management is to communicate the answers to patients' questions about diet in a way that motivates them to apply the information. Here are some motivational strategies that may be effective.

The treatment of polycystic ovary syndrome (PCOS) is based on the patient's presenting symptoms and any significant abnormal findings. Symptoms can be managed with combined oral contraceptives (OCs), insulin-sensitizing agents, antiandrogens, and medications used to induce ovulation.

A long list of foodstuffs have been blamed for the nation's increasingly widespread weight and health problems. Now the spotlight has been turned not on what Americans eat--but on what they drink.

A 68-year-old man presented with diplopia, progressive dyspnea, leg swelling, weakness, night sweats, and a 9-kg (20-lb) weight loss. He had been healthy up until 2 weeks earlier, when the symptoms started. The patient's medical, social, and family history was noncontributory.

BOSTON - Symptoms of gastroesophageal reflux disease increase progressively with increasing body mass indices, even among normal-weight women, according to data from the Nurses' Health Study.

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.