Showing papers in "Cleveland Clinic Journal of Medicine in 2002"
TL;DR: Treatment of asymptomatic hyperuricemia is not necessary in most patients, unless perhaps they have very high levels of uric acid or are otherwise at risk of complications, such as those with a personal or strong family history of gout, urolithiasis, or uric Acid nephropathy.
Abstract: Treatment of asymptomatic hyperuricemia is not necessary in most patients, unless perhaps they have very high levels of uric acid or are otherwise at risk of complications, such as those with a personal or strong family history of gout, urolithiasis, or uric acid nephropathy.
119 citations
TL;DR: Patients at risk for renal adverse effects from NSAIDs can be prospectively identified, and the following patient populations are at higher risk for increases in blood pressure with concomitant use of an NSAID and an antihypertensive.
Abstract: Despite the ubiquitous use of both over-the-counter and prescription nonsteroidal anti-inflammatory drugs (NSAIDs), clinical syndromes-NSAID-related hypertension, salt and water retention, edema, and hyperkalemia-are highly infrequent. Nevertheless, they remain a concern, and patient populations at risk for renal adverse effects from NSAIDs can be prospectively identified. Patients at risk include those with age-related declines in glomerular filtration rate; those with hypovolemia, particularly patients taking loop diuretics; and those with congestive heart failure, cirrhosis, or nephrosis. The following patient populations are at higher risk for increases in blood pressure with concomitant use of an NSAID and an antihypertensive: those with congestive heart failure, liver disease, or kidney disease, and those taking angiotensin-converting enzyme inhibitors or diuretics. Nonselective NSAIDs and COX (cyclooxygenase)-2-selective inhibitors (coxibs) appear to have similar effects on renal function if dosed equivalently, and standard precautions to avoid renal toxicity with use of nonselective NSAIDs apply to coxibs.
108 citations
TL;DR: Many drugs can injure the kidneys, but they cause renal injury via only a few common mechanisms and patients who develop renal injury after drug exposure have identifiable risk factors that should preclude the use of these drugs in the first place.
Abstract: Many drugs can injure the kidneys, but they cause renal injury via only a few common mechanisms. Many patients who develop renal injury after drug exposure have identifiable risk factors that could be modified or that should preclude the use of these drugs in the first place.
107 citations
83 citations
TL;DR: It is believed that very-low-carbohydrate diets merit further study for weight loss, and that criticisms of these diets lack scientific evidence.
Abstract: Much scientific and anecdotal data demonstrate favorable metabolic responses to very-low-carbohydrate diets. We believe that very-low-carbohydrate diets merit further study for weight loss, and that criticisms of these diets lack scientific evidence.
81 citations
78 citations
TL;DR: Primary care physicians need to understand the risks and benefits to help patients determine if this therapy is a good option, and they need to know the health changes that may occur after surgery when following these patients.
Abstract: Bariatric surgery is not a cure, but it can take weight off and keep it off, improve most obesity-related conditions, reduce the risk of premature death, and improve quality of life. Given the interest in the procedure, primary care physicians need to understand the risks and benefits to help patients determine if this therapy is a good option, and they need to know the health changes that may occur after surgery when following these patients.
76 citations
TL;DR: A better understanding of immunologic events involved in granuloma formation and maintenance will allow us to more precisely modulate the granulomatous inflammatory response to the benefit of patients with both infectious and autoimmune diseases.
Abstract: The pathogenesis of granulomatous inflammation is complex and involves a variety of mechanisms acting in concert to bring about an inflammatory lesion that is able to contain and destroy intracellular pathogens. While this process is crucial to host defense, it is also a two-edged sword in that excessive or inappropriate granulomatous inflammation results in considerable damage to normal tissue. In recent years, there has been significant progress in dissecting the immunologic events involved in granuloma formation and maintenance. A better understanding of these events will allow us to more precisely modulate the granulomatous inflammatory response to the benefit of patients with both infectious and autoimmune diseases.
71 citations
TL;DR: The different pathologic features of different types of necrotizing vasculitis indicate that there are different pathogenic mechanisms causing the injury.
Abstract: The different pathologic features of different types of necrotizing vasculitis indicate that there are different pathogenic mechanisms causing the injury. The pathogenic mechanisms for medium-sized-vessel vasculitis are most effective at causing injury in arteries and are not effective at causing injury in smaller vessels. The predilection of medium-sized-vessel vasculitis for bifurcations may relate to the increased expression of adhesion molecules and increased numbers of intimal macrophages at these sites. The preferential involvement of small vessels by small-vessel vasculitis may relate to the requirement for close apposition between leukocytes and endothelial cells for the pathogenic mechanisms to be operational. The pathology of the necrotizing vasculitis of Kawasaki disease is most consistent with a primary role for monocytes/macrophages and T lymphocytes in the acute injury. The pathology of the necrotizing vasculitis of polyarteritis nodosa and small-vessel vasculitis, including ANCA-vasculitis, is most consistent with a primary role for neutrophils and monocytes in the acute injury.
63 citations
TL;DR: The proper steps to take when investigating and treating chemosensory difficulties are reviewed, as lost or impaired smell or taste should be taken seriously.
Abstract: Lost or impaired smell or taste should be taken seriously, as it puts a person at higher risk for toxic exposures, such as gas leaks, smoke, and rotting food, and it also takes away the enjoyment of some of life’s pleasures, such as the fragrance of flowers or the taste of good food or fine wine. In many patients, the loss follows a viral upper respiratory tract infection, and the only real treatment is to reassure patients that the problem may resolve if the damaged sensory cells regenerate. In other patients, the loss has more subtle causes and deserves a careful investigation and appropriate treatment. This article reviews the proper steps to take when investigating and treating chemosensory difficulties.
59 citations
TL;DR: Clinical studies of the COX-2-selective inhibitors rofecoxib and celecoxib have demonstrated efficacy equivalent to nonselective NSAIDs with lower rates of GI side effects, and Selective COx-2 inhibitors (coxibs) provide effective treatment of pain and inflammation while reducing risk of gastropathy.
Abstract: Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most widely used of all drugs and are the most common medications used by persons aged 65 years or more. NSAIDs have a number of side effects, of which the most prevalent and serious is gastrointestinal (GI) toxicity. GI side effects of NSAIDs range from dyspepsia and gastroduodenal ulcers to serious, potentially fatal GI complications including bleeding and perforation. Serious GI complications often lack warning signs; knowledge of risk factors for NSAID-related gastropathy can identify patients at high risk, allowing for initiation of the appropriate therapeutic intervention. Risk factors include advanced age, NSAID dose, prior GI complications, infection with Helicobacter pylori, and use of corticosteroids and anticoagulants. There are few well-established strategies to prevent GI complications in NSAID users. Risk assessment and cotherapy with acid suppressors (H2-receptor antagonists and proton pump inhibitors) or prostaglandin replacement (misoprostol) and H pylori eradication are beneficial. Cyclooxygenase-1 (COX-1) is a key enzyme in gastroprotective mucosal defenses, and the best way to prevent GI toxicity is to avoid drugs that inhibit COX-1. Clinical studies of the COX-2-selective inhibitors rofecoxib and celecoxib have demonstrated efficacy equivalent to nonselective NSAIDs with lower rates of GI side effects (for example, incidence of endoscopic ulcers equivalent to placebo). Selective COX-2 inhibitors (coxibs) provide effective treatment of pain and inflammation while reducing risk of gastropathy.
TL;DR: The terminology, epidemiology, and clinical signs associated with elder abuse in the community and practical strategies for intervention are offered.
Abstract: Although reports of elder abuse to official agencies have been steadily increasing, physicians report only 2% of reported cases. Multiple barriers to reporting exist. This article reviews the terminology, epidemiology, and clinical signs associated with elder abuse in the community and offers practical strategies for intervention.
TL;DR: Comparative studies between patients with GCA and those with acute coronary syndromes should enhance the ability to define the principles of arterial wall inflammation, the specifics of injury in that microenvironment, and help in the identification of the eliciting signals.
Abstract: T lymphocytes, encountering stimulatory signals in the adventitia of medium-size arteries, emerge as the key players in inflammation-associated injury pathways. In GCA, all injury mechanisms have been related to effector macrophages. Regulated by IFN-gamma-producing T cells, macrophages commit to distinct avenues of differentiation and acquire a spectrum of potentially harmful capabilities (Figure 1). Macrophages in the adventitia focus on production of pro-inflammatory cytokines. Macrophages in the media specialize in oxidative damage with lipid peroxidation attacking smooth muscle cells and matrix components. These macrophages also supply reactive oxygen intermediates that, in combination with nitrogen intermediates, cause protein nitration of endothelial cells. Production of oxygen radicals is complemented by the production of metalloproteinases, likely essential in the breakdown of elastic membranes. With the fragmentation of the internal elastic lamina, the intimal layer becomes accessible to migratory myofibroblasts that, driven by PDGF, form a hyperplastic intimal layer and cause occlusion of the vessel lumen. Expansion of the hyperplastic intima is accompanied by intense neoangiogenesis, supported by angiogenesis factors that again derive from specialized macrophages. Similarities in injury pathways between GCA and another arterial disease, atherosclerosis, are beginning to be recognized. Specifically, activated T cells and macrophages are increasingly appreciated as key players in the process of instability and rupture of atherosclerotic plaque. A specialized subset of CD4 T cells, CD4+ CD28- T cells, are suspected to participate in tissue injury in the plaque. These T cells are equipped with cytolytic capabilities and release large amounts of IFN-gamma. Comparative studies between patients with GCA and those with acute coronary syndromes should enhance our ability to define the principles of arterial wall inflammation, the specifics of injury in that microenvironment, and help in the identification of the eliciting signals.
TL;DR: The B-type or brain natriuretic peptide assay, a 15-minute bedside blood test, is highly sensitive and fairly specific for diagnosing heart failure and is useful in evaluating suspected heart failure in outpatients and in emergency care.
Abstract: The B-type or brain natriuretic peptide (BNP) assay, a 15-minute bedside blood test, is highly sensitive and fairly specific for diagnosing heart failure and is useful in evaluating suspected heart failure in outpatients and in emergency care. Other uses include screening for left ventricular dysfunction and predicting outcome in patients with an established diagnosis of heart failure or myocardial infarction.
TL;DR: This review summarizes some of the key aspects of COX biochemistry, structure, and function and the evolution of understanding the mechanism of action ofCOX-2-selective inhibitors to provide a framework upon which clinicians can better appreciate current and future therapeutic applications of coxibs.
Abstract: Anti-inflammatory agents have been used for centuries, but only in the last few decades has medical science gained insight into the complex biologic roles of the primary mediators of inflammation, the eicosanoids and their derivatives Detailed understanding of the prostaglandins and leukotrienes provides a framework for the treatment of pain, inflammation, and fever with aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), but these agents have exacted a substantial side effect burden The discovery of cyclooxygenase-2 (COX-2) has guided development of rationally designed therapeutic agents that have the benefits of older NSAIDs with reduced gastrointestinal toxicity Elucidation of the structure of COX isoenzymes has been key in the development of coxibs, the COX-2–selective subset of NSAIDs Methods to determine the degree of COX-2 selectivity have been refined and are indispensable for comparing the relative selectivity of these agents This review summarizes some of the key aspects of COX biochemistry, structure, and function and the evolution of understanding the mechanism of action of COX-2–selective inhibitors The clinical relevance of COX-1 compared with COX-2 inhibition is discussed to provide a framework upon which clinicians can better appreciate current and future therapeutic applications of coxibs
TL;DR: There is evidence suggesting that IL-6 outperforms other chemical markers in detecting disease activity and could, therefore, have a role in monitoring treatment and the potential to be helpful in predicting disease severity and may allow for a tailoring of immunosuppressive therapy.
Abstract: Cytokines are small proteins that serve as chemical messengers between cells, regulating cell growth and differentiation, tissue repair and remodeling, and many aspects of the immune response. Cytokines are instrumental in determining the nature, magnitude, and duration of inflammatory reactions and, as such, represent ideal targets for interfering with pathogenic processes. In OCA and PMR, cytokines are encountered in two locations, the inflammatory infiltrates accumulating in the arterial wall and in the circulation. IL-6, a cytokine involved in stimulating acute-phase responses, is located upstream of many of the laboratory abnormalities considered helpful in diagnosing and managing GCA/PMR, including elevated ESR and CRP. IL-6 has the potential to be helpful in predicting disease severity and may allow for a tailoring of immunosuppressive therapy. There is evidence suggesting that IL-6 outperforms other chemical markers in detecting disease activity and could, therefore, have a role in monitoring treatment. Interesting pathogenic clues have been derived from studies of cytokines produced in the vascular lesions. IFN-gamma has emerged as a key regulator in determining the nature and direction of the inflammatory response. IFN-gamma appears to be critically involved in modulating the process of intimal hyperplasia, the most destructive consequence of vasculitis, and, as such, emerges as a prime target for novel therapeutic approaches.
TL;DR: Learning to recognize when a patient may have low literacy skills and understanding the common ways in which these people misinterpret medical information can help physicians develop strategies to improve patients' health literacy.
Abstract: Health literacy-the ability to understand and act on health information-is essential for high-quality care. Many people, especially the elderly, who bear the greatest burden of disease, have inadequate health literacy. This adversely affects their quality of care, and places increased cost burdens on society. Learning to recognize when a patient may have low literacy skills and understanding the common ways in which these people misinterpret medical information can help physicians develop strategies to improve patients' health literacy.
TL;DR: Physician behavior--not patient noncompliance--is the major cause of poor hypertension control in the United States, and physicians are unlikely to improve unless physicians become more aggressive in treating mildly elevated systolic blood pressure.
Abstract: Physician behavior--not patient noncompliance--is the major cause of poor hypertension control in the United States, many studies show. Hypertension control is unlikely to improve unless physicians become more aggressive in treating mildly elevated systolic blood pressure.
TL;DR: Evidence supports a role for COX-2-derived prostaglandins as key mediators of nociceptive pain and peripheral sensitization (hyperalgesia) in perioperative pain and in acute and postoperative pain management.
Abstract: Postsurgical pain is often undertreated. Opioids are frequently used in perioperative analgesia, but concern about side effects can result in administration of an inadequate dose for pain relief. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used increasingly for postoperative analgesia. The use of balanced analgesia-a combination of opioids, NSAIDs, and local anesthesia utilizing agents from other classes (eg, ketamine, clonidine)-improves the efficacy of pain relief and decreases risk of side effects. While lacking some of the troublesome side effects of opioids, nonselective NSAIDs may cause bleeding as a result of their inhibitory effects on COX-1. For this reason, COX-2-selective inhibitors (coxibs) are attractive opioid-sparing analgesic options in the perioperative setting. Factors in addition to side effects such as time to onset of action, duration of action, maximum pain relief, use of rescue medication, and other factors relevant to a given pain model are important in determining overall analgesic efficacy. Clinical studies show that COX-2-selective inhibitors are effective for the treatment of preoperative and postoperative pain and reduce postsurgical requirements for opioids. This evidence supports a role for COX-2-derived prostaglandins as key mediators of nociceptive pain and peripheral sensitization (hyperalgesia). Pain management in the perioperative setting and the role of COX-2-selective inhibitors in acute and postoperative pain are reviewed here.
TL;DR: The use of coxibs to treat OA and RA is recommended as first-line therapy when symptoms of pain and inflammation are present in patients vulnerable to potential NSAID-associated GI toxicity.
Abstract: Therapy with nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) has long been the cornerstone of pharmacologic management of patients with osteoarthritis (OA) and rheumatoid arthritis (RA). Many patients with OA or RA, however, are at increased risk of developing clinically significant adverse events associated with NSAID therapy, particularly upper gastrointestinal (GI) complications including symptomatic and complicated ulcers. The introduction of cyclooxygenase (COX)-2-selective inhibitors (coxibs) represents a major advance in the pharmacologic approach to the signs and symptoms of arthritis. In addition to the first two members of this class, celecoxib and rofecoxib, other coxibs have been introduced or are in development (valdecoxib, etoricoxib). In numerous clinical trials, coxibs have been shown to be as effective as nonselective NSAIDs in relieving pain and inflammation associated with OA and RA, and notably, with a significantly lower risk of NSAID-type adverse events. The use of coxibs to treat OA and RA is recommended as first-line therapy when symptoms of pain and inflammation are present in patients vulnerable to potential NSAID-associated GI toxicity.
TL;DR: The author advises treatment of stenotic arteries that are potentially dangerous or that adversely affect lifestyle with either percutaneous transluminal angioplasty or surgery.
Abstract: Takayasu's disease affects young females in the second and third decade of life. During the chronic phase, the aorta and its major arteries become stenotic, causing significant sequelae. Surgical treatment is possible with expectation of good results. The author advises treatment of stenotic arteries that are potentially dangerous or that adversely affect lifestyle with either percutaneous transluminal angioplasty or surgery. The author emphasizes the difference between surgical procedures for atherosclerosis versus a procedure for Takayasu's disease.
TL;DR: Nonsmokers with signs of emphysema at an earlier age than is typical for empysema deserve a workup for one of the less common causes of emphysia, which include alpha 1-antitrypsin deficiency, connective tissue diseases, hypocomplementemic urticarial vasculitis syndrome, intravenous drug use, human immunodeficiency virus infection, and several rare metabolic disorders.
Abstract: Nonsmokers with signs of emphysema at an earlier age than is typical for emphysema deserve a workup for one of the less common causes of emphysema, which include alpha 1-antitrypsin deficiency, connective tissue diseases, hypocomplementemic urticarial vasculitis syndrome, intravenous drug use, human immunodeficiency virus infection, and several rare metabolic disorders.
TL;DR: In this article, a review of classification schemes for dilated cardiomyopathy and the current range of diagnostic and therapeutic options and treatment goals is presented, along with treatment goals.
Abstract: While researchers try to elucidate the origins of idiopathic dilated cardiomyopathy, clinicians continue to face the challenges of identifying and treating the causes of this condition to improve symptoms and survival. We review classification schemes for dilated cardiomyopathy and the current range of diagnostic and therapeutic options and treatment goals.
TL;DR: A formal disease-management program for heart failure should include palliative care, which should include treating the symptoms of end-stage heart failure.
Abstract: Patients with heart failure have special palliative care needs, but palliative measures for treating the symptoms of end-stage heart failure have been largely ignored. A formal disease-management program for heart failure should include palliative care.
TL;DR: Management of idiopathic retroperitoneal fibrosis typically includes surgery, drugs, and drug treatment, or a combination of both, but no surgical or medical therapy has been tested in a randomized, controlled trial.
Abstract: Prompt diagnosis of idiopathic retroperitoneal fibrosis improves chances of preserving renal function, preventing involvement of other organs, and relieving symptoms. Computed tomography or magnetic resonance imaging helps to exclude secondary causes, but open biopsy remains the gold standard for diagnosis. Management typically includes surgery (ureterolysis, stent placement), and drug treatment (corticosteroids), or a combination of both. However, no surgical or medical therapy has been tested in a randomized, controlled trial.
TL;DR: The metabolic derangements of type 2 diabetes, the different classes of antihyperglycemic drugs, and strategies for using these drugs rationally are discussed.
Abstract: To achieve glycemic goals in type 2 diabetes, one must usually use combinations of oral agents or oral agents plus insulin. This paper discusses the metabolic derangements of type 2 diabetes, the different classes of antihyperglycemic drugs, and strategies for using these drugs rationally.
TL;DR: Caution is needed when extrapolating data on the prognostic value of coronary calcium quantification to patients with altered calcium metabolism, such as those with chronic renal failure.
Abstract: Evaluation of coronary artery calcium can allow early identification of coronary artery disease in patients with chronic renal failure. Computed tomography (CT) is a noninvasive method for detecting coronary calcium. Several scoring methods can be used to quantify CT-defined calcium load. The additive value of calcium scoring in cardiovascular risk assessment remains controversial. Caution is needed when extrapolating data on the prognostic value of coronary calcium quantification to patients with altered calcium metabolism, such as those with chronic renal failure.
TL;DR: The common causes of hematuria are discussed and how to evaluate it and the differential diagnosis can be simplified with a systematic approach.
Abstract: Many conditions can cause hematuria, but the differential diagnosis can be simplified with a systematic approach. We discuss the common causes of hematuria and how to evaluate it.