The Medical clinics of North America
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Med. Clin. North Am. · Sep 2011
ReviewInsulin resistance: the link between obesity and cardiovascular disease.
There seems to be general agreement that the prevalence of obesity is increasing in the United States and that we are in the midst of an obesity epidemic. The disease-related implications of this epidemic have received an enormous amount of publicity in the popular media, but public awareness of the untoward effects of excess weight has not led to an effective approach to dealing with the dilemma. The gravity of the problem is accentuated in light of the report that only approximately 50% of physicians polled provided weight loss counseling. ⋯ In view of the ineffectiveness of current clinical approaches to weight loss, it seems necessary to recognize that not all overweight/obese individuals are at equal risk to develop CVD and that it is clinically useful to identify those at highest risk. The simplest way to achieve this task seems to be focusing on the CVD risk factors that are highly associated with insulin resistance/hyperinsulinemia. If this is done, then intense efforts at weight control can be brought to bear on those who not only need it the most but also have the most to gain by losing weight.
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Med. Clin. North Am. · Sep 2011
ReviewSurgical approaches to the treatment of obesity: bariatric surgery.
As the obesity epidemic continues to grow in the Unites States, so does the search for the ideal nonsurgical or surgical solution. Bariatric surgery continues to be the most sustainable form of weight loss available to morbidly obese patients. In addition, bariatric surgery has established an acceptable safety profile with respect to morbidity and mortality. ⋯ Additionally, ample evidence suggests that bariatric surgery may increase longevity, particularly through reducing cardiovascular deaths. Although the specific mechanisms involved in the remission of these medical conditions remain to be fully elucidated, it has become clear that bariatric surgery has established a significant and firm role in the treatment of medical comorbidities that result directly from obesity. However, until commercial insurance carriers provide improved coverage for bariatric surgery, patient access to these treatments will remain limited.
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Med. Clin. North Am. · May 2011
ReviewThe evaluation and management of delirium among older persons.
This article reviews the pathophysiology, prevalence, incidence, and consequences of delirium, focusing on the evaluation of delirium, the published models of care for prevention in patients at risk of delirium, and management of patients for whom delirium is not preventable. Evidence on why physical restraints should not be used for patients with delirium is reviewed. Current available evidence on antipyschotics does not support the role for the general use in the treatment of delirium. An example of a restraint-free, nonpharmacologic management approach [called the TADA approach (tolerate, anticipate, and don't agitate)] is presented.
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Diabetes evolves through prediabetes, defined as impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT). Subjects with IFG/IGT have an increased risk of developing diabetes and a higher prevalence of cardiovascular disease than normoglycemic individuals. ⋯ Therefore, an absolute definition of prediabetes may underestimate the implications and vastness of this disorder. Research should focus on these aspects to minimize the risk of developing a preventable condition.
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A rational approach to diagnosing prediabetes is essential to identify those who would benefit from entering diabetes prevention programs. Impaired fasting glucose and impaired glucose tolerance are similar in relation to their ability to identify those at risk of diabetes or cardiovascular disease; however, because they identify different segments of the at-risk population, there is value in undertaking glucose tolerance testing to ensure that both conditions can be diagnosed. Simple noninvasive diabetes risk scores offer a valuable entry point in the diagnosis of prediabetes, enabling the identification of those who need blood testing.