The American journal of medicine
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As our knowledge on the natural history of chronic obstructive pulmonary disease (COPD) progresses, a conceptual model simply based on an accelerated decline of lung function in adult life in response to smoking has become inadequate to capture the complexity of this disease, and increasing attention is being given to possible contributions from events or alterations of developmental processes that take place earlier in life. In addition, a remarkable heterogeneity has emerged among the pathobiological mechanisms that are involved in different phenotypes of COPD, suggesting that an effective disease management will require individualized treatment approaches largely based on the underlying biological mechanisms (endotypes). In this review, we will discuss the many faces of COPD from an epidemiological, pathobiological, and clinical standpoint and argue that airflow limitation encompasses a number of manifestations that are too diverse to be still clustered under the same diagnostic label.
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Patients residing in agricultural communities have a high risk of developing chronic kidney disease. In the Great Plains, geo-environmental risk factors (eg, variable climate, temperature, air quality, water quality, and drought) combine with agro-environmental risk factors (eg, exposure to fertilizers, soil conditioners, herbicides, fungicides, and pesticides) to increase risk for toxic nephropathy. However, research defining the specific influence of agricultural chemicals on the progression of kidney disease in rural communities has been somewhat limited. By linking retrospective clinical data within electronic medical records to environmental data from sources like US Environmental Protection Agency, analytical models are beginning to provide insight into the impact of agricultural practices on the rate of progression for kidney disease in rural communities.
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The treatment of cardiovascular disease in patients with diabetes has seen a sea change in recent years with the development of novel antihyperglycemic agents. The impact of sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs), two medication classes introduced in the United States in the wake of increased scrutiny by the US Food and Drug Administration on cardiovascular disease and antihyperglycemic agents, highlight this progression. ⋯ These developments have led the 2019 American Diabetes Association guidelines to recommend considering each patient's cardiovascular history when selecting antihyperglycemic agents. The goal of this article is to review recent updates and provide relevant strategies for providers on SGLT2 and GLP-1 RAs in treating cardiovascular disease in patients with diabetes.
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For many years after its first description in 1924, thrombotic thrombocytopenic purpura was an intriguing puzzle for clinicians and researchers, not only for its unique pathology, perplexing changes in von Willebrand factor multimers, and high rate of rapid fatality but also for its dramatic response to plasma infusion or exchange. The discovery of ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats member-13) and its deficiency in patients with thrombotic thrombocytopenic purpura, due to inhibitory autoantibodies or genetic mutations, provides a mechanistic scheme for understanding its pathogenesis. ⋯ Recently, caplacizumab, a bivalent nanobody targeting the glycoprotein 1b binding epitope of von Willebrand factor A1 domain, was approved as an addition to the current regimen of plasma exchange and immunomodulation for adult patients of acquired thrombotic thrombocytopenic purpura. This review discusses how the new treatment may improve patient outcomes and its potential pitfalls.
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Thirty-two percent of US health care spending goes to hospital care, and 20% goes to physicians' charges. The cost of hospital care in the United States is 2-3 times greater than in most similar countries. A large part of the high cost is due to a very large administrative overhead. ⋯ As physicians are increasingly employed by hospitals rather than independent, costs go up with no added benefit to patients. The United States has too many specialists and too few primary care physicians. Practice guidelines are slanted to favor expensive treatments, often with little solid evidence behind the recommendations.