1/6. Recognizing the faces of hypothyroidism.physicians may not recognize hypothyroidism if they rely on the stereotypical picture of the disorder. The age of the patient, stage of the disease, and other illnesses or conditions such as pregnancy can change the clinical presentation. The signs and symptoms of hypothyroidism are remarkably diverse. Instead of a single picture, physicians need a mental gallery.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/6. gout, bradycardia, and hypercholesterolemia after renal transplantation.Approximately 17,000 solid organ transplantations are done annually in the united states. Increasingly, care of these patients will be provided by primary care physicians. In this report, we illustrate the complexity of common medical problems in a patient who had cellulitis and who had had a cadaveric renal transplantation 10 years earlier. Immunosuppressive therapy was cyclosporine (100 mg twice a day) and prednisone (10 mg once a day). The patient's hospital course was complicated by acute gout and symptomatic bradycardia. In both instances, usual treatment--full-dose indomethacin for gout and withholding verapamil for bradycardia--could have had significant interaction with the cyclosporine. At the time of discharge, a therapeutic plan for long-term management of hypercholesterolemia included possible drug interactions with cyclosporine. The potential for drug toxicity in the transplant patient necessitates careful monitoring of immunosuppressive drug levels. Ongoing communication with the transplant center is also needed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/6. Management of high blood cholesterol by primary care physicians: diffusion of the National Cholesterol education Program adult Treatment Panel guidelines.OBJECTIVE: To study knowledge of and adherence to National Cholesterol education Program adult Treatment Panel (ATP) guidelines among primary care physicians. DESIGN: Cross-sectional telephone survey. SETTING: new york State primary care practitioners; survey conducted November 1988-January 1989. PARTICIPANTS: physicians in general practice, family practice, internal medicine without subspecialty, and cardiology who reported greater than or equal to 10 hours/week of clinical practice (n = 329; response rate = 63%). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: While 84% of physicians had heard of the ATP guidelines, gaps in knowledge and inconsistencies between ATP recommendations and clinical practices were found. Although the ATP guidelines recommend six months of dietary therapy before starting drug treatment, 41% of physicians would initiate drug treatment for a healthy 40-year-old man with total cholesterol of 7.8 mmol/L (300 mg/dl) either at the initial visit or after one month of lipid-lowering diet. multivariate analysis of a 24-item knowledge scale revealed that less knowledgeable physicians were more likely to be older, lack board certification, and have a specialty other than cardiology (p less than 0.01). Less knowledgeable physicians were also more likely to consider drug company literature and drug company representatives very useful sources of information about cholesterol (p = 0.02). CONCLUSION: This study suggests that hard-to-reach physician groups may require special efforts to communicate consensus guidelines of major importance to clinical practice.- - - - - - - - - - ranking = 10keywords = physician (Clic here for more details about this article) |
4/6. Nicotinic acid-induced fulminant hepatic failure.A 46-year-old man began taking nicotinic acid, 3 g daily, for hypercholesterolemia. A month later, he developed clinical and biochemical evidence of modest hepatocellular injury, and therapy was stopped. It was restarted 6 weeks later, and 10 weeks after that, the patient presented with fulminant hepatic failure, which resolved rapidly after cessation of nicotinic acid therapy. We suggest that nicotinic acid was the cause of his liver disease, that this case is of particular note because of the rather short period of therapy before the onset of liver injury and the severity of the hepatic failure, and that the probable increased use of nicotinic acid for serum cholesterol control makes it especially important for physicians and their patients to be alert to the signs of hepatotoxicity.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/6. Intrahepatic cholestasis during nicotinic acid therapy.BACKGROUND: Nicotinic acid, widely used to lower serum cholesterol levels, may rarely cause cholestatic jaundice. SUMMARY: A 61-year-old white man with hypercholesterolemia complained of marked pruritus and became jaundiced after taking 3.0 g of crystalline nicotinic acid daily for 13 months. His total serum bilirubin level was increased at 144 mumol/L (8.4 mg/dL) and his alkaline phosphatase level was markedly elevated at 35.00 mukat/L (2100 U/L). Endoscopic retrograde cholangiopancreatography failed to demonstrate an obstructive lesion in the extrahepatic biliary system, computed tomography showed no intrahepatic dilatation, and ultrasonographic studies of the liver, gallbladder, and pancreas were normal; these factors all suggest intrahepatic cholestasis. Symptoms improved and liver function test results returned to normal within 51 days after stopping the drug. CONCLUSIONS: Nicotinic acid-induced cholestatic jaundice may not be as rare as previously thought, and physicians should observe their patients for it.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/6. Guidelines and reported practice for the treatment of hypertension and hypercholesterolaemia.OBJECTIVE: To monitor changes in family physicians' reported practice on hypertension and hypercholesterolaemia. DESIGN: Random samples of physicians were selected for telephone interviews on their practice regarding cut-off levels and pharmacological treatment of hypertension and hypercholesterolaemia, related to a case scenario of a 48-year-old man, in 1989, 1991 and 1993. SETTING: Primary care facilities in southern sweden. SUBJECTS: Specialists in family medicine, employed in public primary health care. Participation rates were in 187/201 (93%) in 1989, 236/264 (89%) in 1991 and 257/298 (86%) in 1993. MAIN OUTCOME MEASURES: Cut-off levels and drug treatment preferences for hypertension and hypercholesterolaemia. RESULTS: During the period 1989-1993, decreasing mean cut-off levels for pharmacological treatment of hypertension (P < 0.001) were reported, below the levels of the guidelines. Although betablockers were first choice drug in all three surveys, the proportion preferring this has diminished (P < 0.001), whilst the proportions preferring ACE-inhibitors and calcium channel blockers have increased (P < 0.001 and P = 0.02, respectively). For drug treatment of hypercholesterolaemia, the mean cut-off level remained close to guidelines in all three surveys. The proportion of physicians suggesting resins and nicotinic acid as first choice drug had decreased (P < 0.001 and P = 0.03, respectively), whilst the proportion preferring statins and fibrates had increased (P < 0.001 and P = 0.048, respectively). CONCLUSION: Practice guidelines on hypertension and hypercholesterolaemia have not had the desired impact on physicians' reported practice. The reason for this might be that physicians did not value the guidelines as adequate tools for practice, or that the methods for dissemination, implementation, and maintenance of guidelines were not appropriate.- - - - - - - - - - ranking = 5keywords = physician (Clic here for more details about this article) |