Detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III)

Population-based epidemiologic studies have uncovered the high prevalence and wide severity spectrum of undiagnosed obstructive sleep apnea, and have consistently found that even mild obstructive sleep apnea is associated with significant morbidity. Evidence from methodologically strong cohort studies indicates that undiagnosed obstructive sleep apnea, with or without symptoms, is independently associated with increased likelihood of hypertension, cardiovascular disease, stroke, daytime sleepiness, motor vehicle accidents, and diminished quality of life. Strategies to decrease the high prevalence and associated morbidity of obstructive sleep apnea are critically needed. The reduction or elimination of risk factors through public health initiatives with clinical support holds promise. Potentially modifiable risk factors considered in this review include overweight and obesity, alcohol, smoking, nasal congestion, and estrogen depletion in menopause. Data suggest that obstructive sleep apnea is associated with all these factors, but at present the only intervention strategy supported with adequate evidence is weight loss. A focus on weight control is especially important given the expanding epidemic of overweight and obesity in the United States. Primary care providers will be central to clinical approaches for addressing the burden and the development of cost-effective case-finding strategies and feasible treatment for mild obstructive sleep apnea warrants high priority.

Epidemiology of obstructive sleep apnea: a population health perspective.

Advances in flavonoid research since 1992.

Polyphenols are the most abundant antioxidants in the diet and are widespread constituents of fruits, vegetables, cereals, dry legumes, chocolate, and beverages, such as tea, coffee, or wine. Experimental studies on animals or cultured human cell lines support a role of polyphenols in the prevention of cardiovascular diseases, cancers, neurodegenerative diseases, diabetes, or osteoporosis. However, it is very difficult to predict from these results the effects of polyphenol intake on disease prevention in humans. One of the reasons is that these studies have often been conducted at doses or concentrations far beyond those documented in humans. The few clinical studies on biomarkers of oxidative stress, cardiovascular disease risk factors, and tumor or bone resorption biomarkers have often led to contradictory results. Epidemiological studies have repeatedly shown an inverse association between the risk of myocardial infarction and the consumption of tea and wine or the intake level of some particular flavonoids, but no clear associations have been found between cancer risk and polyphenol consumption. More human studies are needed to provide clear evidence of their health protective effects and to better evaluate the risks possibly resulting from too high a polyphenol consumption.

Dietary polyphenols and the prevention of diseases

Summary
BACKGROUND AND OBJECTIVE The original Whlckham Survey documented the prevalence of thyroid disorders in a randomly selected sample of 2779 adults which matched the population of Great Britain in age, sex and social class. The aim of the twenty-year follow-up survey was to determine the Incidence and natural history of thyroid disease in this cohort.

DESIGN, PATIENTS AND MEASUREMENTS Subjects were traced at follow-up via the Electoral Register, General Practice registers, Gateshead Family Health Services Authority register and Office of Population Censuses and Surveys. Eight hundred and twenty-five subjects (30% of the sample) had died and, In addition to death certificates, two-thirds had Information from either hospital/General Practitioner notes or post-mortem reports to document morbidity prior to death. Of the 1877 known survivors, 96% participated in the follow-up study and 91 % were tested for clinical, biochemical and Immunological evidence of thyroid dysfunction.

RESULTS Outcomes in terms of morbidity and mortality were determined for over 97% of the original sample. The mean Incidence (with 95% confidence Intervals) of spontaneous hypothyroidism in women was 3.5/1000 survivors/year (2.8-4.5) rising to 4.1/1000 survivors/year (3.3-5.0) for all causes of hypothyroidism and in men was 0.6/1000 survivors/year (0.3-1.2). The mean incidence of hyperthyroidism In women was 0.8/1000 survivors/year (0.5.1.4) and was negligible in men. Similar incidence rates were calculated for the deceased subjects. An estimate of the probability of the development of hypothyroidism and hyperthyroidism at a particular time, i.e. the hazard rate, showed an Increase with age In hypothyroidism but no age relation in hyperthyroidism.

The frequency of goitre decreased with age with 10% of women and 2% of men having a goitre at follow-up, as compared to 23% and 5% in the same subjects respectively at the first survey. The presence of a goitre at either survey was not associated with any clinical or biochemical evidence of thyroid dysfunction. In women, an association was found between the development of a goitre and thyroid-antibody status at follow-up, but not initially.

The risk of having developed hypothyroidism at follow-up was examined with respect to risk factors Identified at first survey. The odds ratios (with 95% confidence Intervals) of developing hypothyroidism with (a) raised serum TSH alone were 8 (3-20) for women and 44 (19-104) for men; (b) positive anti-thyroid antibodies alone were 8 (5-15) for women and 25 (10-63) for men; (c) both raised serum TSH and positive anti-thyroid antibodies were 38 (22-65) for women and 173 (81-370) for men. A loglt model Indicated that Increasing values of serum TSH above 2mU/l at first survey Increased the probability of developing hypothyroidism which was further Increased in the presence of anti-thyroid antibodies. Neither a positive family history of any form of thyroid disease nor parity of women at first survey was associated with Increased risk of developing hypothyroidism. Fasting cholesterol and triglyceride levels at first survey when corrected for age showed no association with the development of hypothyroidism In women.

CONCLUSIONS This historical cohort study has provided Incidence data for thyroid disease over a twenty-year period for a representative cross-sectional sample of the population, and has allowed the determination of the importance of prognostic risk factors for thyroid disease Identified twenty years earlier.

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The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey

Ovarian cancer is the most common fatal gynecological malignancy, responsible for more deaths than all other forms of gynecological cancer combined. Lifetime risks for development of the disease are estimated to lie in the range of 1 in 80 to 1 in 100, with a population prevalence of approximately 30 per 100,000 women. Most patients with the disease present at an advanced stage, with 30% surviving for 5 years with a diagnosis of stage 3 epithelial malignancy (representing local and pelvic extraperitoneal spread) while only 5%–10% survive with stage 4 disease (disseminated malignancy).

Production of Inhibin-Related Peptides by Ovarian Tumors

The assessment of female sexual dysfunction (FSD) is often challenging in the clinical setting. Although androgen deficiency is regarded as a major cause for FSD, the causes of this condition are multifactorial. Women presenting with FSD require thorough clinical evaluation to determine the cause of FSD. Androgen therapy should be used in women only when clinical and biochemical parameters indicate that FSD stems from androgen deficiency. This review outlines the various causes of FSD, clinical and biochemical investigations required to diagnose androgen deficiency, and options for treatment of the woman found to have androgen deficiency as a cause of FSD.

Clinical evaluation of women presenting with low libido and determination of whether androgen therapy might be appropriate.

Publisher Summary This chapter discusses the disorders of pituitary–gonadal function. A variety of lesions at the level of the hypothalamus, pituitary, or gonad may lead to disordered gonadal function, resulting in one or more of a number of specific clinical syndromes, depending on the nature of the disorder and the patient's sex and stage of sexual development at the time of its onset. Sexual ambiguity at birth reflects abnormalities of fetal sexual differentiation. Most cases of sexual ambiguity represent disorders of phenotypic sex in patients whose chromosomal and gonadal sex are concordant and clearly male or female. The clinical syndromes resulting from such disorders are designated male and female pseudohermaphroditism, respectively. Disorders of gonadal and chromosomal sex are much rarer causes of sexual ambiguity and produce a somewhat different clinical picture. Female pseudohermaphroditism results from virilization of an otherwise normal female fetus by excessive levels of androgen. Such infants have ovaries, fallopian tubes, uterus, and vagina, but the clitoris is hypertrophied and the labia majora rugose and bulbous, with variable degrees of fusion.

Disorders of Pituitary-Gonadal Function

In a study of the endocrinology of the perimenopausal years, levels of serum FSH, estradiol (E,), immunoreactive inhibin (INH), testosterone, and sex hormone-binding globulin were measured in a population-based sample of 380 women (mean age, 49.4 yr; range, 45.656.9 yr). Subjects were divided into women who reported continuing regular menstrual cycles (27%; group I), a change in menstrual flow without a change in frequency (23%; group II), a change in frequency but no change in flow (9%; group III), changes in both frequency and flow (28%; group IV), and at least 3 months since their last menstrual period (13%; group V). After adjusting for age and body mass index, the geometric mean FSH increased across menstrual groups and, compared with group I, was 53% higher in group IV (P < 0.0005) and 253% higher in group V (P < 0.0001). Age- and body mass indexadjusted geometric means for E, and INH in group V were 54% and 53% of those in group 1, respectively (P < 0.005, P < 0.0001). Women in group V who did not have a menstrual period in the next year had higher FSH and lower E, and INH levels than those who subsequently went on to have at least one more menstrual period (P < 0.05). FSH was negatively correlated with E, (r = -0.30) and INH (r = -0.39), whereas INH was positively correlated with E, (r = 0.45). We conclude that an increase in serum FSH and decreases in E, and INH are the major endocrine changes associated cross-sectionally with the menopausal transition. (J Clin Endocrinol Metub 80: 3537-3545, 1995)

of the Menopausal Transition: A Cross-Sectional Study of a Population-Based Sample*

Publisher Summary This chapter describes the assessment of the cervical mucus. Mucus is a hydrogel whose components change markedly in response to the circulating level of estrogen and progesterone. Estrogenic mucus (type E) is thin and watery with a protein content of less than 1%, a mucin content of 0.5–1.5%, and few cells present. The physical properties of cervical mucus exhibit a changing pattern in response to the hormonal changes during the menstrual cycle. These changes provide a clinical index of ovarian function, which can be utilized by either the gynecologist or the patient. Gynecological assessment is used in the evaluation of the infertile couple to assess the time of ovulation for treatments, such as artificial insemination and in vitro fertilization, ascertaining that there is a response to ovulation induction and in the study of the cervical factor in subfertility. Patient self-assessment can be used both to enhance fertility by appropriate timing of intercourse and for fertility regulation based on periodic abstinence from intercourse during the fertile phase of the cycle.

Henry G. Burger

Papers

Production of Inhibin-Related Peptides by Ovarian Tumors

Clinical evaluation of women presenting with low libido and determination of whether androgen therapy might be appropriate.

Disorders of Pituitary-Gonadal Function

of the Menopausal Transition: A Cross-Sectional Study of a Population-Based Sample*

Cervical Mucus Assessment