Postgraduate medicine
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Postgraduate medicine · Nov 2011
ReviewIntensive glycemic control and cardiovascular disease: are there patients who may benefit?
Cardiovascular disease (CVD) is the major cause of morbidity and mortality in patients with type 2 diabetes mellitus (T2DM). Recent major publications, such as the Action to Control Cardiovascular Risk in Diabetes trial, the Advance in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation trial, and the Veterans Affairs Diabetes Trial, found that intensive glucose control in patients with T2DM did not reduce CVD outcomes. ⋯ In contrast, more aggressive glucose lowering in older patients with a longer duration of T2DM, a history of CVD, and/or multiple comorbidities does not translate to reduced cardiovascular events, and may cause harm. The target goal and therapeutic strategy for intensive glucose control should be established for each individual after a careful review of his or her medical and psychosocial history, and should not reflect a "one-size-fits-all" approach.
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Chronic pain is inadequately treated in many patients, which has led clinicians and researchers to investigate new indications for existing medications with pain-relieving or adjuvant properties. These medications are known as coanalgesics. ⋯ An update on emergent treatments and uses is also presented. The goals of this article are to highlight coanalgesic treatment options that are currently available for patients with chronic pain as well as provide guidelines for their use in clinical practice.
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Postgraduate medicine · Nov 2011
The pharmacologic basis for clinical differences among GLP-1 receptor agonists and DPP-4 inhibitors.
The incretin system plays an important role in glucose homeostasis, largely through the actions of glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1). Unlike GIP, the actions of GLP-1 are preserved in patients with type 2 diabetes mellitus, which has led to the development of injectable GLP-1 receptor (GLP-1R) agonists and oral dipeptidyl peptidase-4 (DPP-4) inhibitors. GLP-1R agonists-which can be dosed to pharmacologic levels-act directly upon the GLP-1R. ⋯ The main AEs associated with DPP-4 inhibitors include upper respiratory tract infection, nasopharyngitis, and headache. Overall, compared with other therapies for type 2 diabetes mellitus with similar efficacy, incretin-based agents have low risk of hypoglycemia and weight gain. However, GLP-1R agonists demonstrate greater comparative efficacy and weight benefit than DPP-4 inhibitors.
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A significant proportion of the workforce in industrialized countries (16%) are employed as shift workers. These workers may be susceptible to shift work disorder (SWD), a circadian rhythm sleep disorder, particularly those who work at night or on early-morning shifts. Shift work disorder remains an underdiagnosed and undertreated problem among this population. ⋯ In addition, medications that contain melatonin or caffeine may have clinical benefits in some patients with SWD. However, modafinil and armodafinil are approved by the US Food and Drug Administration to improve wakefulness in patients with excessive sleepiness associated with SWD, and recent data suggest a clinical benefit. The use of these therapies can significantly improve sleep, performance, and quality of life for patients with SWD.
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Postgraduate medicine · Sep 2011
ReviewReview of current guidelines on the care of postherpetic neuralgia.
An unfortunate minority of patients with acute herpes zoster (AHZ) experience pain beyond the typical 4-week duration, and roughly 10% develop the distressing complication of postherpetic neuralgia (PHN), often defined as pain persisting for > 4 months after the onset of the rash. Elderly patients are at increased risk of PHN. The pathophysiology of PHN is complex, likely involving both peripheral and central processes. ⋯ Therapies that have demonstrated effectiveness for other types of neuropathic pain are discussed, such as serotonin-norepinephrine reuptake inhibitors, the anticonvulsants carbamazepine and valproic acid, and botulinum toxin. Invasive procedures such as sympathetic blockade, intrathecal steroids, and implantable spinal cord stimulators have been studied for relief of PHN, mainly in patients refractory to noninvasive pharmacologic interventions. The main guidelines considered here are those issued by the American Academy of Neurology for the treatment of postherpetic neuralgia (2004) and general guidelines for the treatment of neuropathic pain issued by the Special Interest Group on Neuropathic Pain of the International Association for the Study of Pain (2007) and the European Federation of Neurological Societies (2010).