1/15. Transactions in a support group meeting: a case study.Following bariatric surgery, the inclusion of a support group as part of the treatment plan makes after-care easier and more efficient for the patients, as well as for the physicians. The following is presented for the education of the medical community. It represents one exemplary session which incorporates the elements necessary for effective after-care: 1. Encouragement for compliance and praise for success. 2. education about life-after-surgery, including nutrition, exercise and dieting techniques. 3. Identification of problems. 4. Identification and development of new kinds of self-nurturing. 5. Participation in a forum where others really "understand" the challenges and difficulties associated with "change," even when the change is for the better. 6. Creation of a "safe harbor" where patients can bring spouses, parents and significant others so that they may also understand, encourage continuing success, and recognize their own personal issues related to the major changes that they are also experiencing with their loved one. 7. Opportunity for curious potential patients in the community to come and learn from the "experts" in an atmosphere of true caring and concern.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/15. The management of adult obesity.obesity is canada's most prevalent metabolic disease: one-third of Canadians are obese. It is a major cause of type 2 diabetes, hypertension, hyperlipidaemia, and atherosclerosis. The treatment of disease caused by obesity accounts for an estimated 2.4 percent of canada's health care expenditures for all diseases (1.8 billion dollars in 1997). This article presents a treatment algorithm based on a number of international guidelines and aimed to help physicians play a more active role in the management of adult obesity. Two problems are briefly examined: pregnancy and stopping cigarettes smoking.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/15. Management of dyslipidemias in the age of statins.Evidence for the effectiveness of lipid-lowering therapy in reducing CHD risk continues to emerge. In primary prevention, clinical trials have demonstrated a benefit for middle-aged, high-risk men with high LDL cholesterol and, more recently, for men and women with "average" LDL and low HDL cholesterol. Although low HDL cholesterol, small dense LDL particles, elevated lipoprotein (a), elevated apolipoprotein B, and the dyslipidemia of the metabolic syndrome pose an increased in CHD risk in some patients, the risk reduction with lipid-lowering therapy has not been fully investigated. The CHD risk of isolated hypertriglyceridemia remains uncertain. Very high triglyceride levels, however, should be treated to prevent pancreatitis. A lipid-lowering diet and other appropriate lifestyle changes constitute safe advice for all patients with dyslipidemia. In initiating pharmacologic therapy, physicians should view potential risk reduction in the context of a patient's overall CHD risk. The selection of particular medications can be individualized, considering effectiveness evidence from clinical trials, lipid-lowering potency, adverse effects, drug interactions, costs, and patient preferences.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/15. Speaking of weight: how patients and primary care clinicians initiate weight loss counseling.BACKGROUND: obesity is epidemic in the US and other industrialized countries and contributes significantly to population morbidity and mortality. Primary care physicians see a substantial portion of the obese population, yet rarely counsel patients to lose weight. methods: Descriptive field notes of outpatient visits collected as part of a multimethod comparative case study were used to study patterns of physician-patient communication around weight control in 633 encounters in family practices in a Midwestern state. RESULTS: Sixty-eight percent of adults and 35% of children were overweight. Excess weight was mentioned in 17% of encounters with overweight patients, while weight loss counseling occurred with 11% of overweight adults and 8% of overweight children. In weight loss counseling encounters, patients formulated weight as a problem by making it a reason for visit or explicitly or implicitly asking for help with weight loss. Clinicians did so by framing weight as a medical problem in itself or as an exacerbating factor for another medical problem. CONCLUSIONS: Strategies that increase the likelihood of patients identifying weight as a problem, or that provide clinicians with a way to "medicalize" the patient's obesity, are likely to increase the frequency of weight loss counseling in primary care visits.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
5/15. Bacterial pituitary abscess: an unusual cause of panhypopituitarism.OBJECTIVE: To describe a case of primary bacterial pituitary abscess manifesting as hypopituitarism. methods: We present the case history, hormonal and bacteriologic data, and findings on imaging studies in a 34-year-old man. RESULTS: The patient had an 8-month history of intermittent fever, headache, nausea, vomiting, and weight loss. Because a computed tomographic scan of the head showed a cystic sellar mass with ring enhancement, he was referred to our medical center. On physical examination, he showed signs of meningeal irritation and had mild hypotension. Hormonal evaluation revealed evidence of hypocortisolism, hypothyroidism, and hypogonadism. Three weeks after treatment with antibiotics and hormonal replacement, he underwent transsphenoidal surgical exploration and evacuation of purulent material from the sella. On culture, this specimen grew coagulase-negative staphylococci and propionibacterium granulosum. Nine months later, dynamic testing showed persistent central hypocortisolism, hypothyroidism, and hypogonadism. CONCLUSION: Bacterial pituitary abscess is rare but manifests similar to other pituitary masses with headaches, visual field defects, and hormonal disturbances. For the correct preoperative diagnosis of this condition, the physician must have a high index of suspicion, and the characteristic ring enhancement must be present on imaging studies.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/15. pathology case of the month. 39-year-old woman with abdominal pain and weight loss. Takayasu's arteritis (TA).A 39-year-old white woman presented with a history of aortoiliac occlusive disease diagnosed in 1992 attributed to oral contraceptive use. Shortly thereafter, aortoiliac replacement was performed. Mild hyperlipidemia was diagnosed in 2001. At the current clinic visit, she presented to her primary care physician with a 3-month history of postprandial midepigastric abdominal pain relieved by vomiting and a 30-pound weight loss. Her evaluation included an esophagogastroduodenoscopy, a colonoscopy, and an abdominal ultrasound, all of which were within normal limits. Because of her medical history, the patient underwent an arteriogram, which revealed brachiocephalic stenosis (Figure 1), occlusion of the left subclavian artery (Figures 2a and 2b), and narrowing of the superior and inferior mesenteric arteries (not shown). Since she had discontinued her oral contraceptives in 1992 and her hyperlipidemia was mild, the rheumatology service was consulted to evaluate this patient. On physical examination, she had decreased left brachial and radial pulses and a right carotid bruit. Laboratory evaluation revealed a normal complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, and C - reactive protein. Subsequent testing included a prothrombin time, activated partial thromboplastin time, protein s, protein c, reptilase time, antithrombin iii, anticardiolipin antibody, antiphospholipid antibody, lupus anticoagulant, homocysteine, RPR, and a lipid profile. All test results were within normal limits. Due to the severity of her abdominal pain, the patient underwent superior mesenteric artery (SMA) bypass surgery. Sections from the aorta resected in 1992 are shown in Figures 3 and 4.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/15. Difficulties in making the diagnosis of hirschsprung disease in early infancy.This study highlights the less common presentations of hirschsprung disease (HD) and HD-associated enterocolitis (HAE) in neonates and infants. We present three infants whose diagnosis was delayed because of atypical presenting features, especially with failure to gain weight, decreased appetite, episodes of diarrhoea and vomiting and hypoalbuminaemia. The reported incidence of HAE ranges from 0 to 16.2%. To avoid complications of life-threatening HAE, primary care physicians require a high index of suspicion of the more unusual presentations of HD in neonates and infants.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/15. Fumbled handoffs: one dropped ball after another.Missed follow-up of abnormal test results and resultant delays in diagnosis is a safety issue that is gaining increasing attention. Despite increases in the numbers and types of available diagnostic tests, current systems in health care do not reliably ensure that test results are received and acted upon by ordering physicians. This article examines the case of a patient whose diagnosis of tuberculosis was substantially delayed because of systems problems, including poor continuity (with multiple-provider involvement), lack of communication of test results and other clinical information, and several handoffs. Strategies to ensure adequate communication of critical information and follow-up of test results are discussed, such as explicit criteria for communication of abnormal results, test-tracking systems for ordering providers, and use of information technologies.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/15. polycystic ovary syndrome and severe nonalcoholic steatohepatitis: beneficial effect of modest weight loss and exercise on liver biopsy findings.OBJECTIVE: To report a case of biopsy-documented nonalcoholic steatohepatitis (NASH), which improved appreciably through moderate exercise and weight loss in a young woman with polycystic ovary syndrome (PCOS) and insulin resistance. methods: We present a detailed case report, including laboratory and pathologic findings. In addition, we review the recent literature regarding the association of insulin resistance with NASH and PCOS. RESULTS: A 24-year-old woman was referred to the Duke gastroenterology Clinic for evaluation of long-term high serum aminotransferase levels. She also reported a history of chronically irregular menses, infertility, and hirsutism and was diagnosed with PCOS. Subsequent glucose tolerance testing suggested the presence of insulin resistance. Liver biopsy findings were consistent with severe nonalcoholic steatohepatitis. Under the supervision of her physician and an exercise physiologist, the patient initiated a diet and exercise program that resulted in an 11.5% weight loss during approximately 8 months and yielded normalization of her aminotransferase levels. A repeat liver biopsy done 13 months after the initial biopsy revealed a substantial decrease in steatosis and a reduction in inflammation. CONCLUSION: women with PCOS and insulin resistance have an increased risk of developing many of the consequences of the dysmetabolic syndrome, including type 2 diabetes, hypertension, and hyperlipidemia. This case report suggests that fatty liver and NASH may be other important diseases to identify in such women. It also demonstrates the improvement in this condition with moderate exercise and weight loss.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/15. Acquired QT prolongation associated with esophagitis and acute weight loss: how to evaluate a prolonged QT interval.When the physician is confronted with a patient having significant QT prolongation, it is critical to determine whether the patient harbors a genetic defect and a transmissible form of long qt syndrome (LQTS) or whether the QT prolongation has an acquired cause. The distinction has profound ramifications for the type of care provided to the patient and family. We report the case of a previously healthy 14-year-old boy who presented with a 10-day history of painful swallowing, a 10-lb weight loss, and chest pain. A 12-lead electrocardiogram (ECG) showed marked QT prolongation. endoscopy and culture identified a herpes simplex esophageal ulcer. After treatment with acyclovir, the patient recovered completely. Three weeks after the resolution of his symptoms and recovery from his acute weight loss, a follow-up ECG showed complete normalization of the QT interval. This case illustrates yet another potential mechanism for acquired QT prolongation. We also provide a diagnostic algorithm for the careful evaluation of a prolonged QT interval.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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