1/3. Pseudoascites in the clinical setting: avoiding unwarranted and futile paracenteses.ascites is diagnosed on physical exam by findings of abdominal distension, bulging flanks, shifting dullness and a prominent fluid wave. However, as the following cases demonstrate, these signs may also be positive in pseudoascites due to thick layers of adipose tissue in the abdomen. A history of recent food binging and a lack of a prolonged prothrombin time should raise the index of suspicion for pseudoascites in a patient with a protuberant abdomen. In light of equivocal physical signs, physicians may employ ultrasonography to prevent patients with pseudoascites from suffering multiple futile attempts at paracentesis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/3. Failure of insulin treatment in obese patients with non-insulin-dependent diabetes mellitus.A number of experts recommend the use of insulin for patients with non-insulin-dependent diabetes mellitus (NIDDM) who fail to respond to diet, exercise, and oral hypoglycemics, even when the patient is morbidly obese. This article describes the use of insulin in two obese patients with NIDDM whose obesity worsened following the institution of insulin therapy. In some cases the risk for increased obesity and its complications following the institution of insulin may offset the potential benefits of insulin therapy itself. There are two main drawbacks associated with insulin therapy in these patients. First, from a medical point of view, insulin has a lipogenic effect and may actually contribute to weight gain, hyperinsulinemia, and increased insulin resistance in obese patients with NIDDM. Second, from a behavioral point of view, the institution of insulin therapy may shift the patient's and physician's focus from the preferred lifestyle adjustments to the numerous details associated with insulin use and monitoring. Since weight gain and sedentary activity are themselves risk factors for coronary artery disease, the benefits of decreased blood glucose levels should be balanced against the risk of increased weight gain in these patients.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/3. Decision tree and postpartum management for preventing dehydration in the "breastfed" baby.dehydration and poor weight gain in breastfed infants are common but potentially preventable problems. Serious consequences are severe hypernatremic dehydration, severe weight loss, and severe hyperbilirubinemia with possible irreversible damage to the baby's brain or other vital organs. The dangers of dehydration have been emphasized by recent media reports of severe cases. These reports have resulted in increased, but often inappropriate, intervention in breastfeeding. On the basis of our experience at the Hospital for Sick Children, and the Doctors Hospital (Toronto), we have developed a decision tree and management protocol to assess breastfeeding, intervene effectively, and prevent such problems. If all breastfeeding mothers and babies are evaluated by qualified staff before discharge using this tool, it is expected that the serious consequences associated with babies leaving hospital appearing to be breastfeeding, but in fact not breastfeeding at all, will be prevented. Application of this approach, however, will require considerable upgrading of nurses' and physicians' skills and knowledge with regard to breastfeeding. A case report is presented.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |