The Medical clinics of North America
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In the United States, the costs associated with diabetes mellitus are increasing. Although people with diabetes comprise less than 6% of the US population, approximately 1 in 5 health care dollars is spent caring for people with diabetes. Healthy lifestyle interventions for the general population and intensive lifestyle and medication interventions for high-risk individuals present opportunities for diabetes prevention. This article describes the costs associated with glucose intolerance and diabetes, the effect of glucose intolerance and diabetes on the quality of life, and the cost-effectiveness of screening and primary prevention interventions for diabetes prevention.
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A variety of definitions and diagnostic cutpoints have been promulgated for prediabetes without universal agreement. Professional organizations agree that current scientific evidence justifies intervention in high-risk populations for the delay or prevention of progression to diabetes. Lifestyle intervention is universally accepted as the primary intervention strategy. Secondary intervention is advocated in high-risk individuals or in the absence of a clinical response to lifestyle modification.
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Identifying individuals at increased risk of developing diabetes has assumed increasing importance with the expansion of the evidence from clinical trials on the prevention or delay of type 2 diabetes using lifestyle modification and medication. The epidemiology of prediabetes depends on the diagnostic method used. Glucose measures defining impaired glucose tolerance and impaired fasting glucose levels identify about 10% of the adults to have prediabetes, whereas glycated hemoglobin-based criteria identify a significantly lower proportion of the population. Increasingly, multifactorial risk tools are being used and cut-points set to identify approximately 15% of the population as being at high risk.
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The evaluation and management of renal cell carcinoma (RCC) has evolved in recent decades in response to the changing clinical presentation of the disease. Traditional teaching suggested that RCC usually presents with signs or symptoms. However, RCC discovered this way was usually locally advanced and often metastatic, requiring radical nephrectomy in most cases but often having a poor prognosis. ⋯ This change has prompted a significant RCC stage migration over the past 20 years, with most kidney tumors seen in 2010 being smaller, organ-confined, and appropriate for nephron-sparing approaches with the anticipation of a favorable outcome. The approach to addressing patients with these incidentally detected, often localized, small renal masses raises different concerns than those for traditional patients presenting with symptomatic RCC. This article reviews the modern epidemiology of RCC, outlines the components of the evaluation of the incidental renal mass, details the current options of management, and discusses the long-term expectations for these patients.