Showing papers in "Primary Care in 2003"

The menopause and obesity.

Abstract: Obesity is a major health problem in the United States. It is estimated that 61% of the U.S. population is either overweight or obese (Body Mass Index 25 kg/m 2 ) [1]. According to the most recent National Health and Nutrition Examination Survey (NHANES III, 1988–1994), the prevalence of obesity is substantially higher in women (24.9%) than in men (19.9%) [1]. Additionally, 8.4% of women and 3.9% of men aged 25 to 34 years experience a major weight gain (greater than 10 kg) [2]. For women in the early menopausal years (aged 50 to 59 years), the prevalence of obesity increased by 47% between 1991 and 1998 [3]. Obesity is particularly common among minority women. In NHANES III, nearly 40% of black women and 34% of Mexican-American women had a BMI that was greater than 30 kg/m 2 [1]. Among some Native American groups, more than 50% to 80% of the adult women are obese [4] (p. 142S). Furthermore, among women but not men, poverty or low socioeconomic status is a risk factor for obesity. The prevalence of obesity in women at, or below, the poverty level is approximately 50%, regardless of ethnic group; women in higher income groups have significantly lower prevalence rates [4] (p. 146S). At any level of BMI, women have a greater percentage of body fat than men, so a woman’s risk of being ‘‘overfat’’ is higher, even at BMIs that are within the normal range. For example, Blew et al [5] recently assessed the relationship between BMI and percentage of fat in 317 postmenopausal women aged 40 to 66 years. Using 38% fat as a criterion for obesity, the cutoff BMI in this population was 24.9 kg/m 2 . Wellens et al [6] similarly suggested that a BMI of 23 kg/m 2 might provide a better cutoff for defining obesity in premenopausal white women, based on their percentage of body fat.

Herbal preparations for obesity: are they useful?

Abstract: The opportunities for additional research in this area are plentiful. Unfortunately, there has been relatively limited funding for research on herbal supplements compared with the amount of funding that is available for research on pharmaceuticals. Botanical dietary supplements often contain complex mixtures of phytochemicals that have additive or synergistic interactions. For example, the tea catechins include a group of related compounds with effects that are demonstrable beyond those that are seen with epigallocatechin gallate, the most potent catechin. The metabolism of families of related compounds may be different than the metabolism of purified crystallized compounds. In some cases, herbal medicines may simply be less purified forms of single active ingredients, but in other cases they represent unique formulations of multiple, related compounds that may have superior safety and efficacy compared with single ingredients. Obesity is a global epidemic, and traditional herbal medicines may have more acceptance than prescription drugs in many cultures with emerging epidemics of obesity. Several ethnobotanical studies found herbal treatments for diabetes, and similar surveys, termed bioprospecting, for obesity treatments may be productive. Beyond increasing thermogenesis, there are other biological rationales for the actions of several different alternative medical and herbal approaches to weight loss. For example, several supplements and herbs claim to result in nutrient partitioning so that ingested calories will be directed to muscle, rather than fat. These include an herb (Garcinia cambogia), and a lipid which is the product of bacterial metabolism (conjugated linoleic acid). Moreover, a series of approaches attempt to physically affect gastric satiety by filling the stomach. Fiber swells after ingestion and has was found to result in increased satiety. A binding resin (Chitosan) has the ability to precipitate fat in the laboratory and is touted for its ability to bind fat in the intestines so that it is not absorbed. In double-blind studies, however, this approach was found to be ineffective. There are two key attractions of alternative treatments to obese patients. First, they are viewed as being natural and are assumed by patients to be safer than prescription drugs. Second, there is no perceived need for professional assistance with these approaches. For obese individuals who cannot afford to see a physician, these approaches often represent a more accessible solution. Finally, for many others, these approaches represent alternatives to failed attempts at weight loss with the use of more conventional approaches. These consumers are often discouraged by previous failures, and are likely to combine approaches or use these supplements at doses higher than are recommended. It is vital that the primary care physician is aware of the herbal preparations that are being used by patients so that any potential interaction with prescription drugs or underlying medical conditions can be anticipated. Unfortunately, there have been several instances where unscrupulous profiteers have plundered the resources of the obese public. Although Americans spend $30 billion per year on weight loss aids, our regulatory and monitoring capability as a society are woefully inadequate. Without adequate resources, the FDA resorted to "guilt by association" adverse events reporting, which often results in the loss of potentially helpful therapies without adequate investigation of the real causes of the adverse events that are reported. Scientific investigations of herbal and alternative therapies represent a potentially important source for new discoveries in obesity treatment and prevention. Cooperative interactions in research between the Office of Dietary Supplements, the National Center for Complementary and Alternative Medicine, and the FDA could lead to major advances in research on the efficacy and safety of the most promising of these alternative approaches.

Microbiology and management of human and animal bite wound infections

Abstract: This article describes the microbiology, diagnosis, and management of human and animal bite wound infections. Various organisms can be recovered from bite wounds that generally result from aerobic and anaerobic microbial flora of the oral cavity of the biting animal, rather than the victim's own skin flora. The role of anaerobes in bite wound infections has been increasingly appreciated. Anaerobes were isolated from more than two thirds of human and animal bite wound infections, especially those associated with abscess formation. This article describes several of the organisms found in the bites of various species. In addition to local wound infection, other complications may occur, including lymphangitis, local abscess, septic arthritis, tenosynovitis, and osteomyelitis. Rare complications include endocarditis, meningitis, brain abscess, and sepsis with disseminated intravascular coagulation, especially in immunocompromised individuals. Wound management includes the administration of proper local care and the use of proper antimicrobial agents when needed.

Risks of obesity

Abstract: Obesity is a chronic disease in the same sense as hypertension and atherosclerosis. The cause of obesity is an imbalance between the energy ingested in food and the energy expended. The excess energy is stored in fat cells that enlarge or increase in number. This hyperplasia and hypertrophy of fat cells is the pathologic lesion of obesity. Enlarged fat cells produce the clinical problems that are associated with obesity, either because of the weight or mass of the extra fat or because of the increased secretion of free fatty acids and numerous peptides from enlarged fat cells. The consequence of these two mechanisms is other diseases, such as diabetes mellitus, gallbladder disease, osteoarthritis, heart disease, and some forms of cancer.

The management of the obese diabetic patient.

Abstract: The prevalence of obesity and diabetes is increasing in the United States and worldwide. These diseases are predicted to explode to epidemic proportions, unless appropriate counteractive measures are taken. Several large studies (DCCT, UKPDS, Kumamoto) clearly showed that intensive glycemic control in the diabetic patient reduced microvascular complications and improved mortality. Despite this, the NHANES III showed that only 50% of diabetics have been able to achieve a HgbAic level that is less than 7%; this suggests the need for a re-evaluation of our approach to these patients. The management of the obese diabetic patient involves glycemic control and weight reduction. These goals are particularly difficult to achieve in the obese diabetic patient because progressive beta-cell dysfunction and increasing insulin resistance necessitates the administration of increasingly higher dosages of insulin, which, in turn, promotes weight gain. A vicious cycle may ensue. Lifestyle modifications with diet and exercise are an essential part of the management of the obese diabetic patient. These measures alone are often insufficient and concomitant pharmacologic therapy is usually required to achieve glycemic and weight control. Oral agents that improve glycemia, decrease insulin resistance, and limit weight gain are desirable. Because of the progressive nature of diabetes, glycemic control with monotherapy often deteriorates over time, which necessitates the addition of other pharmacologic agents, including insulin. When insulin therapy is required in the treatment of the obese diabetic patient, combinations with oral agents that have been shown to minimize the amount of exogenous insulin that is required, may minimize weight gain. In addition, the obese diabetic patient who is poorly controlled with maximum oral hypoglycemic therapy may benefit from weight-reducing agents, such as sibutramine or orlistat. The introduction of these agents at other points in the management of the obese diabetic patients have been successful. Finally, for the severely obese diabetic patient, bariatric surgery may be the only effective treatment. Gastric bypass has been unequivocally shown to produce significant weight loss and improve glycemic control on a long-term basis in the obese diabetic patient. It is recommended that physicians avail themselves of all of these strategies in the management of the obese patient who has type 2 diabetes.

Community-acquired pneumonia in adults.

Abstract: The most common etiologic agent of CAP is Streptococcus pneumoniae. Atypical pathogens are the cause in approximately 20% to 30% of patients. Because the patients clinical presentation cannot be used to predict if a patient is infected with S. pneumoniae or an atypical pathogen, the initial empiric therapy should cover for these core organisms in all patients. In patients with CAP, the antibiotic spectrum of initial empiric therapy will escalate from an oral macrolide in an ambulatory patient without risk factors for resistant pathogens, to intravenous combination therapy, in a hospitalized patient in the intensive care unit with risk factors for resistant gram-negative organisms. The hospitalized patient can be switched safely from intravenous to oral therapy once he or she reaches clinical stability. The use of pneumococcal vaccine, influenza vaccine, and smoking-cessation programs is an important strategy to prevent CAP.

Management of patients on chronic glucocorticoid therapy: an endocrine perspective

Abstract: Glucocorticoids continue to be a potent therapeutic tool for various medical conditions; however, their medication side effects pose challenges. Steroid diabetes is treated primarily with prandial insulin, either regular or the rapid insulins (lispro or aspart). Intermediate insulin is indicated less frequently, for fasting hyperglycemia. Osteoporosis is the most debilitating of potential glucocorticoid side effects, with bisphosphonates the mainstay of prevention and treatment. Dyslipidemia can range from mild to significant, but it responds to therapy similar to that of nonglucocorticoid-induced lipid disorders. Glucocorticoid-induced adrenal withdrawal syndrome can occur even with short courses of longer-acting glucocorticoid therapy, but it responds to adjustment of glucocorticoid dose. When tapering down to near-physiologic dose, pituitary-adrenal axis responsiveness should be checked before discontinuing steroid use.

Preventing cardiovascular disease in diabetes and glucose intolerance: evidence and implications for care.

Abstract: With the increased attention being given to cardiovascular risk factor reduction, the opportunity exists to substantially decrease the largest cause of mortality in diabetic patients. The concept that type 2 diabetes and CVD are linked via a common etiologic pathway (metabolic syndrome) has substantial ramifications for the care of individual patients. Many of the metabolic abnormalities that contribute to both glycemic disorders and CVD are interrelated. For example, hyperinsulinemia and insulin resistance coupled with abdominal obesity further worsens HTN and hyperlipidemia. Likewise, the procoagulant state and endothelial dysfunction increase with worsening glycemic control. Specific interventions include tobacco cessation, a food management and physical activity plan, choice of antidiabetic agent (such as metformin), and use of ACE inhibitors for hypertension and microalbuminuria (Table 5). Programs to enhance cardiovascular risk factor reduction as part of the comprehensive evaluation and management of diabetic patients have been described [95,99]. One community-based program provided free screening to diabetic patients with randomization to either annotated result reports provided to the patient and their physician or results provided by a project nurse (either face-to-face or over the phone). Greater improvements in mean glycohemoglobin, cholesterol, and blood pressure were noted with verbal presentation of results [99]. Recent data from the Centers for Disease Control and Prevention Diabetes Cost-effectiveness Group support the idea that interventions to decrease CVD in diabetics are economically beneficial. Intensive management of hypertension, glycemic control, and hyperlipidemia each improved health outcomes. Hypertension control reduced costs. Although intensive treatment of glucose and hyperlipidemia increased costs, the increase was comparable to that of other frequently used health care interventions [100]. Further directions include further exploration of the implications and management of metabolic syndrome as it relates to CVD prevention. Interventions such as exercise, which can impact on all outcomes, require special attention. Efforts by physicians, health systems, and society are necessary to increase physical activity for individuals of all ages. It makes clinical sense that the recommendations for prevention of CVD in diabetics described in this article may also benefit patients with prediabetes (fasting glucose 110-125 mg/dl), but this remains to be definitively shown.

Prevention of type 2 diabetes: data from recent trials.

Abstract: All four main studies of lifestyle intervention on diabetes incidence found a clear benefit for diet and exercise intervention compared with usual care. Although the study populations differed by race and ethnicity, the mean BMI, and the intensity of the lifestyle intervention provided, all investigators found substantial diabetes risk reduction with modest weight loss and increased physical activity. Results of these trials give health care providers useful and heartening information to share with patients at risk for diabetes. The challenge remains to find feasible and cost-efficient methods to identify people at risk and to deliver effective lifestyle interventions. Findings from trials of pharmacologic agents such as metformin, acarbose, and troglitazone are encouraging; however, the ADA recommends that drug therapy should not be used routinely to prevent diabetes until more information regarding the cost-effectiveness of such intervention is known [20]. Results from trials that found a lower incidence of diabetes among those randomly assigned to angiotensin-converting enzyme inhibitors, statins, or hormone therapy are intriguing but must be viewed with caution because they are based on post hoc analyses. Because it is difficult to conduct randomized controlled trials of major operative procedures such as bariatric surgery, observational studies that compare surgical interventions for weight loss with traditional weight-loss management may be the best evidence available. These studies have the potential for healthy-person bias in that people who choose bariatric surgery may have other healthy behaviors that are often difficult to measure and control for; such behaviors could account for their lower incidence of diabetes. Undeniably, the best test to diagnose those at high risk for diabetes is not yet known. New strategies that identify those with pre-diabetes and that overcome the limitations of the current tests, particularly the 2-hour post-challenge glucose test, are needed.

The prevalence of obesity.

Abstract: During the past several decades, obesity has increased substantially, making it a true epidemic and a public health crisis that both health care providers and the public are going to have to face. Currently, 61% of the US population is overweight or obese and therefore at increased risk for a number of diseases that are associated with increased body fat. Indeed, the obesity epidemic already is leading to dramatic increases in type 2 diabetes and the metabolic syndrome. Almost a quarter of the population currently has metabolic syndrome, which places them at high risk for the development of coronary heart disease. The future of the general health of the US population depends on identifying and providing the best treatment and prevention strategies for obesity in the years ahead.

Review articleThyroid disease

Abstract: Evaluation and treatment of thyroid disease is a common feature of primary care medicine. Nevertheless, the dose of thyroid hormone used to treat hypothyroidism is frequently not titrated to normalize the TSH, engendering the risks of under- or overtreatment. Other hypothyroid patients remain symptomatic even with normalized TSH on levothyroxine alone. Some of these patients improve symptomatically when liothyronine is added to the treatment regimen. Subclinical hypothyroidism and hyperthyroidism are also relatively common in primary care medical practice, and appropriately selected patients probably benefit from treatment. In the follow-up of patients treated for thyroid cancer, the use of rhTSH improves patient comfort considerably while allowing sensitive screening for persistent or recurrent cancer.

Urinary tract infections.

Abstract: Infection of the urinary tract is the commonest renal disease seen in nephrological practice and second only to infections of the respiratory tract in overall clinical practice. With the widespread and early use of antibiotics over the past three decades it was hoped that some of the problems caused by urinary tract infections would be eliminated.

Evaluation of body composition: practical guidelines

Abstract: The measurement of body composition in the truest sense allows for the estimation of body tissues, organs, and their distributions in living persons without inflicting harm. It is important to recognize that there is no single measurement method that is error-free. Furthermore, bias can be introduced if a measurement method makes assumptions related to body composition proportions and characteristics that are inaccurate across different populations. Some methodologic concerns include hydration of fat-free body mass changes with age and differences across ethnic groups [73]; the density of fat-free body mass changes with age and differences between men and women [74, 75]; total body potassium decreases with age [73] and fatness [76] and differences between African Americans and Caucasians [77]; the mass of skeletal muscle differences across race group [63]; and VAT differences across sex [78] and race [67, 79, 80] groups, independent of total adiposity. These between-group differences influence the absolute accuracy of methods for estimating fatness or FFM that involve the two-compartment model approach. The clinical significance of the body compartment to be measured should be determined before a measurement method is selected, because the more advanced techniques are less accessible and more costly.

Polycystic ovary syndrome: a review for primary providers.

Abstract: PCOS is a metabolic syndrome that exists throughout the world with much clinical heterogeneity. PCOS is now appreciated as encompassing two interrelated metabolic phenomena--insulin resistance and hyperandrogenism. Patients present with oligo-amenorrhea and clinical hyperandrogenism, and the diagnosis is based on clinical grounds with few laboratory tests necessary. Because patients are at higher than normal risk for diabetes, glucose intolerance, and hyperlipidemia, and perhaps at higher risk for coronary heart disease, newly diagnosed patients with PCOS should be evaluated for glucose intolerance and hyperlipidemia. The cornerstone of therapy today includes weight management, and further therapeutic intervention is focused on reproductive and cardiovascular health and treatment of insulin resistance. Clinical case continued The 17-year-old mentioned in the beginning of this article probably does have PCOS. She fits the clinical criteria: oligo-ovulation and hyper-androgenism (the acne and hirsutism). In addition, she is obese, which is also associated with PCOS. Her TSH and prolactin were normal, and as her presentation was not suggestive of an adrenal tumor or congenital adrenal hyperplasia (she had mild hirsutism, and those diagnoses are associated with more severe hyperandrogenism), no further laboratory evaluation was deemed necessary. Once the diagnosis was made, she was screened for lipid abnormalities and for glucose intolerance. Her LDL was 150, HDL 35; oral glucose tolerance test (OGTT) was normal. A pregnancy test was negative, and she was started on OCPs. Devoting herself to exercise and dietary change, she lost 10 pounds in her first 3 months after diagnosis. Her hirsutism and acne have improved with the OCPs and weight loss, and her menses are regular. She has elected to defer oral insulin sensitizers until her weight loss has stabilized. Findings PCOS is common in reproductive-aged women. Diagnosis is clinical and is supported by lab findings; there is significant clinical heterogeneity. Insulin resistance is likely central to the pathophysiology along with androgen excess. Health implications include infertility, diabetes, endometrial cancer, hyperlipidemia, and possibly coronary heart disease. Treatment is evolving and includes weight loss, OCPs, and insulin sensitizers.

Problems in childhood obesity.

Abstract: Clearly, obesity prevention should be at the forefront of our approach to this epidemic problem and the goal of health care providers, public health officials, community, and families. The problems of the obese child are no longer solely those of increased risk for disease, but of disease itself. Health care providers are increasingly challenged to provide evaluation and treatment for the serious comorbidities and complications of obesity in childhood. Many of these comorbidities and complications are "invisible" and require careful and focused history and laboratory evaluation to elicit. Treatment of the complication and comorbidity should be focused on preventing progression, reversing the disease process, and, ultimately, achieving control of obesity with family-based lifestyle changes that will allow the child to maintain a healthy balance between his or her genetic predisposition and the environment.

Diagnosis and management of pituitary tumors: recent advances

Abstract: In recent years, the medical therapy for prolactinomas and GH-secreting adenomas has greatly improved due to the availability of new, highly effective, long-acting dopamine and somatostatin analogues. Although medical therapy has for some time been the first-line approach to prolactinoma management, the incidence of patients requiring surgery for resistance or intolerance/noncompliance is likely to decrease substantially with these new agents. Increasing efficacy and greater ease of administration of somatostatin analogues for GH, and for rare TSH, adenomas are also anticipated to lead to less reliance on surgery and radiation therapy as the primary therapy in these disorders. Although somewhat unclear at this time, GH antagonists hold promise for alternative or adjunct therapy for acromegaly. Given the significant morbidity and mortality associated with acromegaly, these advances are quite encouraging. Unfortunately, little if any progress has been made toward establishing an effective medical treatment for gonadotropin or nonsecreting tumors. However, new approaches to delivery of radiation therapy may reduce some of the inconvenience and risk of this treatment for patients when surgery alone is inadequate. In all of these disorders, the challenge to physicians and their patients remains one of choosing a rational combination of medical, surgical, and radiation therapy. Fortunately, for most patients, control, if not cure, of their pituitary adenoma is a reasonable expectation.

Orlistat in the treatment of obesity

Abstract: Orlistat has been well studied in several populations, including patients who do and do not have type 2 diabetes and in patients who have impaired glucose tolerance. Overall, modest, but significant, weight loss was seen in all three groups of patients with favorable effects on the comorbidities of obesity. Orlistat has not been associated with a serious adverse event profile, and the mild GI effects that are seen in some patients are well tolerated. In obese patients who do not have diabetes, weight loss is achieved and maintained as shown in the 2-year studies. Moreover, as was well documented in the Swedish multi-morbidity study, favorable treatment effects on the constituents of the metabolic syndrome are seen. Orlistat, together with a hypocaloric diet, was proven to be effective in preventing diabetes in patients who had impaired glucose tolerance. The addition of orlistat resulted in significant weight loss and significance decreases in levels of HbA1c in patients who had type 2 diabetes who were treated with antihyperglycemic drugs. Studies showed that it is possible to identify early which patients may respond best to treatment. Orlistat offers an attractive treatment option for obese patients who do and do not have diabetes and as a combination drug for treatment of obese patients who have type 2 diabetes.

Medical myths involving diabetes.

Abstract: Medical myths occur for many different reasons. Myths surrounding diabetes are common and are usually attributable to practices that have not been evaluated rigorously (sliding-scale insulin use), concerns related to pathophysiology (beta-blocker use), or extrapolation from small studies or case series (niacin use in patients with diabetes). Myths often are passed on from generation of house staff to students by word of mouth. It is often difficult to determine the origins of some myths, as is the case with sliding-scale insulin use. Other myths may have grown from the inclusion of information from a small case series in an authoritative text [1]. Understanding the myths and misconceptions about the care of patients with diabetes is important in providing excellent care to the patient with diabetes.

Behavioral techniques for treating the obese patient

Abstract: With more than 50% of American adults overweight or obese, primary care physicians should play an active role in helping overweight patients lose weight. Modest weight losses of as little as 7% to 10% can produce significant health benefits, such as preventing the development of diabetes. To help individuals achieve this weight loss, behavior change strategies should be emphasized with all overweight patients. Changes in diet and exercise can produce long-term weight loss with tremendous positive impact. Primary care physicians are well positioned to support these behavior changes in their overweight patients.

Issues in the diagnosis of Cushing's syndrome for the primary care physician.

Abstract: The diagnosis of Cushing's syndrome is one of the most difficult and yet one of the most important ones a primary care physician can make. The clinical presentation overlaps that of many other common diseases, but more specific signs such as unexplained osteoporosis, muscle weakness, ecchymoses, hypokalemia, and central obesity, the presence of multiple symptoms affecting different body systems, and a demonstrated change over time should prompt the screening evaluation. We recommend a step-wise approach to the diagnostic evaluation. Step 1 involves demonstrating pathologic hypercortisolemia and thus making the diagnosis of Cushing's syndrome. In step 2, distinguishing ACTH-independent disease from ACTH-dependent disease and then adrenal imaging is done. Finally, for patients with ACTH-dependent disease, step 3 entails anatomic localization of the ACTH source by MRI, if unequivocal, or by IPSS or CSS. Only when the evaluation is done in a step-wise fashion can the clinician be assured that appropriate treatment recommendations can be made. Although a fair amount of the testing is complex, requiring special facilities and usually the assistance of an endocrinologist, the most critical step is that done by the primary care physician--considering the diagnosis and initiating the screening algorithm.

Male hypogonadism in the primary care clinic.

Abstract: Hypogonadism is common in clinical practice but is frequently unrecognized and underdiagnosed. The common causes of male hypogonadism vary with the age of presentation. The overall prevalence of male hypogonadism based upon low serum total testosterone levels is high and increases with age. There are many pitfalls in making the diagnosis of male hypogonadism. First, male hypogonadism is sometimes difficult to recognize because the signs and symptoms are often nonspecific and overlap with other common syndromes. Second, the biochemical diagnosis of male hypogonadism is not straightforward because it might not be clear which testosterone assay to select from the many that are available. Finally, even after the diagnosis of male hypogonadism is made, the patient and clinician must weigh the potential benefits and risks of androgen replacement therapy. However, new diagnostic tools and therapies are making decisions easier.

Use of sibutramine to treat obesity

Abstract: Medications are useful adjuncts to diet and exercise and may help patients lose weight and maintain significant weight loss (5%-10% from baseline). Pharmacologic approaches are indicated in those patients who have had prior weight-loss attempts, who have a body mass index greater than or equal to 30 kg/m2 or greater than or equal to 27 kg/m2 with comorbidity, and who are motivated and ready to undertake dietary and physical activity changes. This article provides a treatment algorithm to help physicians measure meaningful weight loss and proposes conservative blood pressure limits to guide the long-term prescription of sibutramine. Sibutramine can be a useful tool in the obesity treatment toolbox if used by knowledgeable practitioners.

Osteoporosis management in the new millennium

Abstract: The prevalence of osteoporosis in all US postmenopausal women is 17%, and it is as high as 30% in women older than 65 All postmenopausal women should be encouraged to have adequate daily calcium and vitamin D intake, to exercise regularly, and to avoid tobacco and excessive alcohol use Although the clinical impact and cost-effectiveness of osteoporosis screening tools remain to be established, a rational approach based on current evidence involves using National Osteoporosis Foundation guidelines, Simple Calculated Osteoporosis Risk Estimation, or Osteoporosis Risk Assessment Instrument clinical decision rules to decide when a postmenopausal woman should undergo further evaluation

Skin and subcutaneous infections.

Abstract: Cutaneous infections most commonly are caused by Staphylococcus aureus and GABHS. Life-threatening complications can occur and are preventable with early diagnosis and specific therapy. Dermatophytoses frequently are seen in children and immune-compromised adults with poor hygiene. Sporotrichosis and nontuberculous mycobacteria are ubiquitous and can cause indolent granulomatous lesions. Vesicular and fleshy lesions are manifestations of cutaneous viral infections due to HSV, varicella-zoster virus, molluscum, and human papillomavirus.

Gastroenteritis and antibiotic-associated diarrhea.

Abstract: Acute gastroenteritis is a common cause of emergency and office visits. This article reviews causes, pathogenesis, diagnosis, prevention, and treatment. The incidence of antibiotic-associated colitis is increasing worldwide as a consequence of widespread use of broad-spectrum antibiotics for various illnesses. The pathogenic organism, Clostridium difficile, produces two enterotoxins, toxin A and toxin B, that cause colonic mucosal inflammation. C. difficile infection presents with a wide range of clinical manifestations, from asymptomatic carriers to life-threatening pseudomembranous colitis.

Inpatient management of diabetes.

Abstract: Hyperglycemia is common in hospitalized patients with diabetes and contributes to poor outcomes in this population. Use of intravenous insulin protocols for patients who are unable to take anything by mouth, continuation of usual insulin regimens for those who are eating, pre-meal insulin supplements for hyperglycemia, and avoidance of sliding-scale insulin can help the clinician to improve glycemic control. Careful attention to management of diabetes in the hospitalized patient decreases the risk of ketoacidosis, fluid and electrolyte abnormalities, and infection; in critically ill postoperative patients in a surgical ICU setting, it can decrease the risk of death.

HIV disease in primary care

Abstract: During the past decade, a large number of new drugs for treating HIV and its complications have been developed. The increasingly sophisticated use of these drugs in combination has led to a marked reduction in HIV-related morbidity and mortality in countries where they are available. HIV/AIDS patients receiving treatment are now expected to live into old age. The beneficial effect of HIV treatment has resulted in an expanding population of persons living with HIV/AIDS who will need the care of an HIV specialist because of the complexity of the treatment regimens and the rapidly changing HIV/AIDS knowledge base. However, this growing and aging population will also benefit from the care of a primary care physician. The primary care generalist is in the best position to recognize and diagnose HIV infection, evaluate HIV risk in his or her patient population, and help prevent HIV infection in persons at risk. In patients known to be infected, the primary care generalist will be best able to manage hyperlipidemia, diabetes, cardiovascular disease, and other disorders of an aging population with an increased risk of these and other conditions. Patients with HIV infection frequently accumulate a large number of specialist physicians, and the unique ability of the primary care physician to monitor their care and act as a knowledgeable patient advocate is a great benefit to the patient.

Exercise strategies for the obese patient.

Abstract: Exercise is an important component of weight-control programs, yet the impact of exercise for weight control is based on the ability of patients to engage in adequate levels of activity. The minimal level that should be recommended is at least 30 minutes of moderate-intensity physical activity on most days of the week. Although this level of physical activity may improve health-related factors, there is some evidence to support the recommendation of higher levels of exercise for weight-control purposes. The role of the clinician is to provide adequate guidance to patients regarding issues related to the intensity, duration, and mode of exercise that may be most appropriate. When addressing these issues, it is also important to consider the barriers that individual patients may encounter that will have an effect on adoption and maintenance of exercise behaviors.

Sexually transmitted infections in men

Abstract: Sexually transmitted infections (STIs) are among the most common clinical conditions encountered in primary care and urgent care settings. The prevention, early detection, and effective treatment of STIs represent a significant clinical and public health burden, with a critical role for patient behavioral counseling as an important part of an overall prevention strategy. The majority of clinical care recommendations regarding STIs focus on the care of women, in whom STIs can result in sequelae such as pelvic inflammatory disease (PID), infertility, increased morbidity and mortality during pregnancy, chronic pelvic pain syndromes, neonatal transmission and complications, and others. STIs in women are more frequently evident clinically due to presentation with vaginal discharge or other related symptoms, and they are diagnosed incidentally or during STI screening during routine pelvic examinations as part of an established preventive health program for women.

Infections of the female genital tract.

Abstract: This article discusses infections of the female genital tract, including vaginitis, sexually transmitted diseases, and endometriosis, and includes methods of diagnosis, treatment, and specific management strategies for these infections.