tag:blogger.com,1999:blog-91402901182476417782024-03-05T02:49:56.617-08:00Acute Disease | Diseases | Infectious Diseases | Health PromotionEvery year many people succumb to injuries caused due to accidents or homicides while these incidents are avertible, still a lot more fall prey to deadly dieseases. Most of these diseases are acute and affect people in the worst manner. AcuteDisease tries to put up symptoms, diagnosis and treatment methodologies for these disease, in an attempt to serve the society.Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.comBlogger15125tag:blogger.com,1999:blog-9140290118247641778.post-18711100715547169492012-07-23T11:25:00.000-07:002012-07-23T11:25:49.341-07:00Prevention of Injuries & Violence<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-size: x-large;"><b>Injuries & Violence :</b></span><br /><br />
<div class="contentBody">
Injuries remain the most important cause of loss of
potential years of life before age 65. Homicide and motor vehicle accidents are
a major cause of injury-related deaths among young adults, and accidental falls
are the most common cause of injury-related death in the elderly. Other causes
of injury-related deaths include suicide and accidental exposure to smoke, fire,
and flames. </div>
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<div class="contentBody">
Although there has been a steady decline in motor vehicle
accident deaths per miles driven, road traffic injuries remain the tenth leading
cause of death and the ninth leading cause of the burden of disease. Although
seat belt use protects against serious injury and death in motor vehicle
accidents, at least one-fourth of adults and one-third of teenagers do not use
seat belts routinely. Air bags are protective for adults but not for small
children. </div>
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<div class="contentBody">
Each year in the United States, more than 500,000 people
are nonfatally injured while riding bicycles. The rate of helmet use by
bicyclists and motorcyclists is significantly increased in states with helmet
laws. Young men appear most likely to resist wearing helmets. Clinicians should
try to educate their patients about seat belts, safety helmets, the risks of
using cellular telephones while driving, drinking and driving—or using other
intoxicants or long-acting benzodiazepines and then driving—and the risks of
having guns in the home. </div>
<a href="http://www.blogger.com/blogger.g?blogID=9140290118247641778" name="779271"></a>
<div class="contentBody">
Long-term alcohol abuse adversely affects outcome from
trauma and increases the risk of readmission for new trauma. Alcohol and illicit
drug use are associated with an increased risk of violent death. There is a
causal link between alcohol intoxication and injury due to assault. Harm
reduction can be achieved through practical measures, such as using plastic
glasses and bottles in licensed premises; controlling prices of drinks; and
targeted policing based on police, accident, and emergency data. </div>
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<div class="contentBody">
Males aged 16–35 are at especially high risk for serious
injury and death from accidents and violence, with blacks and Latinos at
greatest risk. For 16- and 17-year-old drivers, the risk of fatal crashes
increases with the number of passengers. Deaths from firearms have reached
epidemic levels in the United States and will soon surpass the number of deaths
from motor vehicle accidents. Having a gun in the home increases the likelihood
of homicide nearly threefold and of suicide fivefold. In 2002, an estimated
877,000 individuals successfully committed suicide. Educating physicians to
recognize and treat depression as well as restricting access to lethal methods
have been found to reduce suicide rates.</div>
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<div class="contentBody">
In elderly patients, the risk of hip fracture when falling
can be reduced by as much as 80% by wearing hip protectors, but only about half
of patients use them regularly. Oral vitamin D supplementation with 700–800
international units/d appears to reduce the risk of hip and other nonvertebral
fractures in both ambulatory and institutionalized elderly persons, but 400
international units/d is not sufficient for fracture prevention.</div>
<a href="http://www.blogger.com/blogger.g?blogID=9140290118247641778" name="70"></a>
<div class="contentBody">
Finally, clinicians have a critical role in detection,
prevention, and management of physical or sexual abuse—in particular, routine
assessment of women for risk of domestic violence. In a trial, the 12-month
prevalence of intimate partner violence ranged from 4% to 18% depending on the
screening method, instrument, and health care setting. Rates of current domestic
violence on exit questionnaire were 21% in suburban emergency department and 26%
in urban emergency department settings. Inclusion of a single question about
domestic violence in the medical history—"At any time, has a partner ever hit
you, kicked you, or otherwise physically hurt you?"—can increase identification
of this common problem. Another screen consists of three questions: (1) "Have
you ever been hit, kicked, punched, or otherwise hurt by someone within the past
year? If so, by whom?" (2) "Do you feel safe in your current relationship?" (3)
"Is there a partner from a previous relationship who is making you feel unsafe
now?" Women seem to prefer written, self-completed screening questionnaires to
face-to-face questioning. Alternatively, computer prompts to clinicians may
serve as useful reminders to inquiry. Assessment for abuse and offering of
referrals to community resources creates potential to interrupt and prevent
recurrence of domestic violence and associated trauma. Screening patients in
emergency departments for intimate partner violence appears to have no adverse
effects related to screening and may lead to increased patient contact with
community resources.</div>
</div>
Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0tag:blogger.com,1999:blog-9140290118247641778.post-29630202111951497492012-07-20T12:35:00.000-07:002012-07-20T12:35:03.688-07:00Cancer Prevention<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-size: x-large;"><b>Prevention of cancer :</b></span><br />
<br />
<div class="contentHead5">
<b>Primary Prevention:</b><br /></div>
<a href="" name="57"></a>
<div class="contentBody">
Mortality rates of cancer have begun to decrease in the
past 2 years; part of this decrease results from reductions in tobacco use,
since cigarette smoking is the most important preventable cause of cancer.
Preventive health examinations and preventive gynecologic examinations are among
the most common reasons for ambulatory care visits, although the use and content
of these types of visits remains controversial. Primary prevention of skin
cancer consists of restricting exposure to ultraviolet light by wearing
appropriate clothing and use of sunscreens. In the past 2 decades, there has
been a threefold increase in the incidence of squamous cell carcinoma and a
fourfold increase in melanoma in the United States. Persons who engage in
regular physical exercise and avoid obesity have lower rates of breast and colon
cancer. Prevention of occupationally induced cancers involves minimizing
exposure to carcinogenic substances such as asbestos, ionizing radiation, and
benzene compounds. Chemoprevention has been widely studied for primary cancer
prevention (see above Chemoprevention section and Chapter 39: Cancer). Use of
tamoxifen, raloxifene, and aromatase inhibitors for breast cancer prevention is
discussed in Chapter 17: Breast Disorders and Chapter 39: Cancer. Hepatitis B
vaccination can prevent hepatocellular carcinoma (HCC), and screening and
vaccination programs may be cost-effective and useful in preventing HCC in
high-risk groups such as Asians and Pacific Islanders. The use of HPV vaccine to
prevent cervical cancer is discussed above in the Prevention of Infectious
Disease section.</div>
<div class="contentBody">
<br /></div>
<div class="contentHead5">
<b>Screening & Early Detection:</b><br /></div>
<a href="" name="59"></a>
<div class="contentBody">
Screening has been shown to prevent death from cancers of
the breast, colon, and cervix. Current cancer screening recommendations from the
American Cancer Society, the Canadian Task Force on Preventive Health Care, and
the United States Preventive Services Task Force are shown in Table 1–9.</div>
<a href="" name="60"></a>
<table bgcolor="#ffffff" border="0" cellpadding="0" cellspacing="0">
<tbody>
<tr>
<td bgcolor="#cccccc" style="border-left: rgb(102,102,102) 1px solid; border-right: rgb(102,102,102) 1px solid; border-top: rgb(102,102,102) 1px solid;">
<table border="0" cellpadding="3" cellspacing="0">
<tbody>
<tr>
<td>
<div class="tableTitle">
<b><span style="color: #990000;">Cancer screening recommendations for average-risk
adults.</span></b></div>
</td></tr>
</tbody></table>
</td></tr>
<tr>
<td>
<table bgcolor="#666666" border="0" cellpadding="3" cellspacing="1">
<colgroup span="4"></colgroup>
<thead>
<tr class="font12">
<th align="left" bgcolor="#ffffff" valign="top">Test</th>
<th align="left" bgcolor="#ffffff" valign="top">ACS<sup>1</sup><br /> </th>
<th align="left" bgcolor="#ffffff" valign="top">CTF<sup>2</sup><br /> </th>
<th align="left" bgcolor="#ffffff" valign="top">USPSTF<sup>3</sup><br /> </th>
<th align="left" bgcolor="#ffffff" valign="top"> </th></tr>
</thead>
<tbody>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Breast self-examination
(BSE)</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">An option for women over
age 20.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Fair evidence that BSE
<i>should not</i> be used. </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Insufficient evidence to
recommend for or against.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Clinical breast
examination </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Every 3 years age 20–40
and annually thereafter.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Good evidence for annual
screening women aged 50-69 by clinical examination and mammography.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Insufficient evidence to
recommend for or against.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Mammography</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Annually age 40 and
older. </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Current evidence does not
support the recommendation that screening mammography be included in or excluded
from the periodic health examination of women aged 40–49.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Recommended every 1–2
years for women aged 40 and over (B).</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Papanicolaou test</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Annually beginning within
3 years after first vaginal intercourse or no later than age 21. Screening may
be done every 2 years with the liquid-based Pap test.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Annually at age of first
intercourse or by age 18; can move to every-2-year screening after two normal
results to age 69.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Every 3 years beginning
at onset of sexual activity or age 21 (A).</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">After age 30, women with
three normal tests may be screened every 2–3 years or every 3 years by Pap test
<i>plus</i> the HPV DNA test. </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Women may choose to stop
screening after age 70 if they have had three normal (and no abnormal) results
within the last 10 years.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Recommends against
routinely screening women older than age 65 if they have had adequate recent
screening with normal Pap tests and are not otherwise at high risk for cervical
cancer (D).</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Annual stool test for
occult blood<sup>4</sup> or fecal immunochemical test (FIT)<br /> </td>
<td align="left" bgcolor="#ffffff" class="font12" rowspan="4" valign="top">Screening
recommended, with the combination of fecal occult blood test or fecal
immunochemical test (FIT) and sigmoidoscopy preferred over stool test or
sigmoidoscopy alone. Double-contrast barium enema and colonoscopy also
considered reasonable alternatives.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Good evidence for
screening every 1–2 years over age 50.</td>
<td align="left" bgcolor="#ffffff" class="font12" rowspan="4" valign="top">Screening
strongly recommended (A), but insufficient evidence to determine best test.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Sigmoidoscopy (every 5
years)</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Fair evidence for
screening over age 50 (insufficient evidence about combining stool test and
sigmoidoscopy).</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Double-contrast barium
enema (every 5 years)</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Not addressed.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Colonoscopy (every 10
years)</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Insufficient evidence for
or against use in screening. </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Prostate-specific antigen
(PSA) blood test</td>
<td align="left" bgcolor="#ffffff" class="font12" rowspan="2" valign="top">PSA and DRE
should be offered annually to men age 50 and older who have at least a 10-year
life expectancy. Men at high risk (African American men and men with a strong
family history) should begin at age 45. Information should be provided to men
about the benefits and risks, and they should be allowed to participate in the
decision. Men without a clear preference should be screened.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Fair evidence
<i>against</i> including in routine care. </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Insufficient evidence to
recommend for or against.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Digital Rectal
Examination (DRE)</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Insufficient evidence for
or against including in routine care. </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Insufficient evidence to
recommend for or against.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Cancer-related
checkup</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">For people aged 20 or
older having periodic health exams, a cancer-related checkup should include
counseling and perhaps oral cavity, thyroid, lymph node, or testicular
examinations.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Not assessed.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Not assessed.</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> </td></tr>
</tbody></table>
</td></tr>
<tr>
<td bgcolor="#ffffff"><br class="Spacer8" /><span class="font11">
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</div>
<table bgcolor="#ffffff" border="0" cellpadding="0" cellspacing="0">
<tbody>
<tr>
<td bgcolor="#ffffff"><span class="font11">
<div class="font12">
<b>Home test with three samples<br /></b></div>
<div class="font12">
<b>Recommendation A: </b>The USPSTF strongly recommends that clinicians
routinely provide the service to eligible patients. (The USPSTF found good
evidence that the service improves important health outcomes and concludes that
benefits substantially outweigh harms.)<br /></div>
<div class="font12">
<b>Recommendation B: </b>The USPSTF recommends that clinicians
routinely provide the service to eligible patients. (The USPSTF found at least
fair evidence that the service improves important health outcomes and concludes
that benefits substantially outweigh harms.)<br /></div>
<div class="font12">
<b>Recommendation D</b>: The USPSTF recommends against routinely
providing the service to asymptomatic patients. (The USPSTF found at least fair
evidence that the service is ineffective or that harms outweigh
benefits.)<br /></div>
</span></td></tr>
</tbody></table>
<a href="" name="61"></a>
<br />
<div class="contentBody">
The appropriate form and frequency of screening for breast
cancer is controversial. A large randomized trial of breast self-examination
conducted among factory workers in Shanghai found no benefit. A systematic
review performed for the United States Preventive Services Task Force found that
mammography was moderately effective in reducing breast cancer mortality for
women 40–74 years of age. The absolute benefit was greater for older women, and
the risk of false-positive results was high for all women. Digital mammography
is more sensitive in women with dense breasts and younger women; however,
studies exploring outcomes are lacking. Several organizations, including the
American Cancer Society and the National Cancer Institute, recommend routine
mammography screening, and changes in screening guidelines appear to impact
women's beliefs about how frequently they should obtain screening. Although
delays to following up an abnormal mammogram exist, the use of patient
navigation programs to reduce such delays appears beneficial, especially among
poor and minority populations. The use of MRI is not currently recommended for
general screening, although the American Cancer Society does recommend screening
MRI for women at high risk (<img border="0" src="" /> 20–25%), including those with a strong family history of breast or
ovarian cancer. A recent systematic review reported that screening with both MRI
and mammography might be superior to mammography alone in ruling out cancerous
lesions in women with an inherited predisposition to breast cancer.</div>
<div class="contentBody">
<br /></div>
<a href="" name="62"></a>
<div class="contentBody">
All current recommendations call for cervical and
colorectal cancer screening. Prostate cancer screening, however, is
controversial, as no completed studies have answered the question whether early
detection and treatment after screen detection produce sufficient benefits to
outweigh harms of treatment. A 2008 USPSTF review of current evidence on
benefits and harm of screening asymptomatic men for prostate cancer with
prostate-specific antigen (PSA) testing revealed that PSA screening is
associated with increased psychological harm with uncertain potential benefits.
Providers and patients are advised to discuss how to proceed in light of this
uncertainty. Whether early detection through screening and subsequent treatment
alters the natural course of the disease remains to be seen. There are still no
data on the morbidity and mortality benefits of screening. Unlike the American
College of Physicians, the American Cancer Society recommends that providers
offer annual PSA testing for men over age 50. Screening is not recommended by
any group for men who have estimated life expectancies of less than 10 years.
Decision aids have been developed to help men weigh the arguments for and
against PSA screening. </div>
<div class="contentBody">
<br /></div>
<a href="" name="64"></a>
<div class="contentBody">
Annual or biennial fecal occult blood testing reduces
mortality from colorectal cancer by 16–33%. The risk of death from colon cancer
among patients undergoing at least one sigmoidoscopic examination is reduced by
60–80% compared with that among those not having sigmoidoscopy. Colonoscopy has
also been advocated as a screening examination. It is more accurate than
flexible sigmoidoscopy for detecting cancer and polyps, but its value in
reducing colon cancer mortality has not been studied directly. Recent studies
have shown that CT colography (virtual colonoscopy) is also able to detect
cancers and polyps with reasonable accuracy.</div>
<div class="contentBody">
<br /></div>
<a href="" name="65"></a>
<div class="contentBody">
Screening for cervical cancer with a Papanicolaou smear is
indicated in sexually active adolescents and in adult women every 1–3 years.
Screening for vaginal cancer with a Papanicolaou smear is not indicated in women
who have undergone hysterectomies for benign disease with removal of the
cervix—except in diethylstilbestrol (DES)-exposed women (see Chapter 18:
Gynecologic Disorders). Women over age 70 who have had normal results on three
or more previous Papanicolaou smears may elect to stop screening.</div>
<a href="" name="776254"></a>
<div class="contentBody">
Screening for lung cancer with spiral CT can detect early
stage disease; however, its efficacy in reducing lung cancer mortality has not
been evaluated in a randomized trial, although a recent study of survival in
asymptomatic patients at risk for lung cancer who were screened annually with
spiral CT revealed that such screening detected lung cancer at a curable stage. </div>
</span></td></tr>
</tbody></table>
<div class="contentBody">
<br /></div>
</div>Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0tag:blogger.com,1999:blog-9140290118247641778.post-21468595282256917832012-07-17T11:46:00.002-07:002012-07-17T11:46:58.343-07:00Prevention of Overweight Obesity<div dir="ltr" style="text-align: left;" trbidi="on">
<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="background-color: white;"><span style="font-size: x-large;"><b>Overweight Obesity:</b></span><br /></span><br />
Obesity is now a true epidemic and public health crisis that both clinicians and patients must face. Normal body weight is defined as a body mass index (BMI), calculated as the weight in kilograms divided by the height in meters squared, of < 25 kg/m2; overweight is defined as a BMI = 25.0–29.9 kg/m2, and obesity as a BMI > 30 kg/m2. The prevalence of obesity in US children, adolescents, and adults has grown dramatically since 1990. In 2003–2004, 17% of US children and adolescents were overweight and 32% of adults were obese. Among men, the prevalence of obesity increased significantly between 1999 and 2000 (28%) and between 2003 and 2004 (31%). Among women, no significant increase in the prevalence of obesity was observed between 1999 and 2000 (33%) or between 2003 and 2004 (33%). The prevalence of extreme obesity (BMI 40) in 2003–2004 was 3% in men and 7% in women. Prevalence varies by race and age, with older African American and Latina women having the greatest prevalence of obesity. This trend has been linked both to declines in physical activity and to increased caloric intake in diets rich in fats and carbohydrates.<br />
<br />
Adequate levels of physical activity appear to be important for the prevention of weight gain and the development of obesity. However, as noted above, only about 20% of Americans are physically active at a moderate level, and only 8% at a more vigorous level, and 60% report irregular or no leisure time physical activity. In addition, only 3% of Americans meet four of the five recommendations for the intake of grains, fruits, vegetables, dairy products, and meat of the Food Guide Pyramid. Only one of four Americans eats the recommended five or more fruits and vegetables per day.<br />
<br />
Risk assessment of the overweight and obese patient begins with determination of BMI, waist circumference for those with a BMI of 35 or less, presence of comorbid conditions, and a fasting blood glucose and lipid panel. Obesity is clearly associated with type 2 diabetes mellitus, hypertension, hyperlipidemia, cancer, osteoarthritis, cardiovascular disease, obstructive sleep apnea, and asthma. One of the most important sequelae of the rapid surge in prevalence of overweight and obesity between 1990 and 2000 has been a dramatic 30–40% increase in the prevalence of type 2 diabetes mellitus. In addition, almost one-quarter of the US population currently has the metabolic syndrome, putting them at high risk for the development of CHD. The relationship between overweight and obesity and diabetes, hypertension, and coronary artery disease is thought to be due to insulin resistance and compensatory hyperinsulinemia. Persons with a BMI 40 have death rates from cancers that are 52% higher for men and 62% higher for women than the rates in men and women of normal weight. Significant trends of increasing risk of death with higher BMIs are observed for cancers of the stomach and prostate in men and for cancers of the breast, uterus, cervix, and ovary in women, and for cancers of the esophagus, colon and rectum, liver, gallbladder, pancreas, and kidney, non-Hodgkin lymphoma, and multiple myeloma in both men and women.<br />
<br />
In the Framingham Heart Study, overweight and obesity were associated with large decreases in life expectancy. For example, 40-year-old female nonsmokers lost 3.3 years and 40-year-old male nonsmokers lost 3.1 years of life expectancy because of overweight, and 7.1 years and 5.8 years of life expectancy, respectively, because of obesity. Obese female smokers lost 7.2 years and obese male smokers lost 6.7 years of life expectancy compared with normal-weight smokers, and 13.3 years and 13.7 years, respectively, compared with normal-weight nonsmokers. Clinicians must work to identify and provide the best prevention and treatment strategies for patients who are overweight and obese. Patients with abdominal obesity (high waist to hip size ratio) are at particularly increased risk. Control of visceral obesity in addition to other cardiovascular risk factors (hypertension, insulin resistance, and dyslipidemia) is essential to reducing cardiovascular risk.<br />
<br />
<b>CURRENT Practice Guidelines in Primary Care :</b><br />
<br />
Prevention of overweight and obesity involves both increasing physical activity and dietary modification to reduce caloric intake. Clinicians can help guide patients to develop personalized eating plans to reduce energy intake, particularly by recognizing the contributions of fat, concentrated carbohydrates, and large portion sizes (see Chapter 29: Nutritional Disorders). Patients typically underestimate caloric content, especially when consuming food away from home. Providing patients with caloric and nutritional information may help address the current obesity epidemic. To prevent the long-term chronic disease sequelae of overweight or obesity, clinicians must work with patients to modify other risk factors, eg, by smoking cessation (see above) and strict glycemic and blood pressure control (see Chapter 27: Diabetes Mellitus & Hypoglycemia and Systemic Hypertension).<br />
<br />
Lifestyle modification, including diet, physical activity, and behavior therapy, has been shown to induce clinically significant weight loss. Other treatment options for obesity include pharmacotherapy and surgery. One potentially effective diet strategy is the replacement of caloric beverages with low-calorie or noncaloric beverages. As noted above, in overweight and obese persons, at least 60 minutes of moderate-high intensity physical activity may be necessary to maximize weight loss and prevent significant weight regain. Counseling interventions or pharmacotherapy can produce modest (3–5 kg) sustained weight loss over 6–12 months. Pharmacotherapy appears safe in the short term; long-term safety is still not established. As an example, in a multicenter trial, treatment with 20 mg/d of rimonabant, a selective cannabinoid-1 receptor blocker, plus diet for 2 years produced modest but sustained reductions in weight and waist circumference and favorable changes in metabolic risk factors. Counseling appears to be most effective when intensive and combined with behavioral therapy. Maintenance strategies can help preserve weight loss.<br />
<br />
In dietary therapy, results from the Women's Health Initiative Dietary Modification Trial showed that a low-fat diet high in vegetables, fruits, and grains produced a modest (2.2 kg, P < .001) weight loss that was sustained over prolonged follow-up (1.9 kg, P < .001 at 1 year, 0.4 kg, P = .01 at 7.5 years). A recent study comparing various diets revealed that Mediterranean (moderate fat, restricted calorie) and low-carbohydrate (non-restricted calorie) diets are effective alternatives to low-fat diets.<br />
<br />
Weight loss strategies using dietary, physical activity, or behavioral interventions can produce significant improvements in weight among persons with prediabetes and a significant decrease in diabetes incidence. Multicomponent interventions including very-low-calorie or low-calorie diets hold promise for achieving weight loss in adults with type 2 diabetes mellitus.<br />
<br />
Bariatric surgical procedures, eg, vertical banded gastroplasty and Roux-en-Y gastric bypass, are reserved for patients with morbid obesity whose BMI exceeds 40, or for less severely obese patients (with BMIs between 35 and 40) with high-risk comorbid conditions such as life-threatening cardiopulmonary problems (eg, severe sleep apnea, pickwickian syndrome, and obesity-related cardiomyopathy) or severe diabetes mellitus. In selected patients, surgery can produce substantial weight loss (10 to 159 kg) over 1 to 5 years, with rare but sometimes severe complications. Nutritional deficiencies are one complication of bariatric surgical procedures and close monitoring of a patient's metabolic and nutritional status is essential.<br />
<br />
Clinicians seem to share a general perception that almost no one succeeds in long-term maintenance of weight loss. However, research demonstrates that approximately 20% of overweight individuals are successful at long-term weight loss (defined as losing 10% of initial body weight and maintaining the loss for 1 year). National Weight Control Registry members who lost an average of 33 kg and maintained the loss for more than 5 years have provided useful information about how to maintain weight loss. Members report engaging in high levels of physical activity (approximately 60 min/d), eating a low-calorie, low-fat diet, eating breakfast regularly, self-monitoring weight, and maintaining a consistent eating pattern from weekdays to weekends. The development and implementation of innovative public health strategies is essential in the fight against obesity. Lessons learned from smoking cessation campaigns may be helpful in the battle against this significant public health concern.<br />
</div>
</div>Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0tag:blogger.com,1999:blog-9140290118247641778.post-48183631046588447432012-07-02T10:17:00.004-07:002012-07-02T10:17:31.423-07:00Prevention of Physical Inactivity<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<b style="font-size: xx-large; text-align: left;">Physical Inactivity :</b>
</div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi71_iV01-dDmuBSBsDD7URGAr1YB2LtoyV5s2ThnDFaFcgPkjdQ_fHOh-OzX_ANW-_9kEOqtIcIgMr3bwejtjdbtR2LWxmMgmLSghA_7DljlcmBTE4Q0swepRPMjzoBzFz4NMHZlXyQpE/s1600/Physical-Inactivity.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="296" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi71_iV01-dDmuBSBsDD7URGAr1YB2LtoyV5s2ThnDFaFcgPkjdQ_fHOh-OzX_ANW-_9kEOqtIcIgMr3bwejtjdbtR2LWxmMgmLSghA_7DljlcmBTE4Q0swepRPMjzoBzFz4NMHZlXyQpE/s320/Physical-Inactivity.JPG" width="320" /></a></div>
<br /><br /><br />
<div class="contentBody">
Lack of sufficient physical activity is the second most
important contributor to preventable deaths, trailing only tobacco use. A
sedentary lifestyle has been linked to 28% of deaths from leading chronic
diseases. The Centers for Disease Control and Prevention (CDC) has recommended
that every adult in the United States should engage in 30 minutes or more of
moderate-intensity physical activity on most days of the week. This guideline
complements previous advice urging at least 20–30 minutes of more vigorous
aerobic exercise three to five times a week. <br /></div>
<a href="" name="49"></a>
<div class="contentBody">
Patients who engage in regular moderate to vigorous
exercise have a lower risk of myocardial infarction, stroke, hypertension,
hyperlipidemia, type 2 diabetes mellitus, diverticular disease, and
osteoporosis. Current evidence supports the recommended guidelines of 30 minutes
of moderate physical activity on most days of the week in both the primary and
secondary prevention of CHD. Between 1980 and 2000, an estimated 5% of the
decrease in US deaths from CHD among adults aged 25–84 years resulted from
increases in physical activity. <br /></div>
<a href="" name="774851"></a>
<div class="contentBody">
In older nonsmoking men, walking 2 miles or more per day is
associated with an almost 50% lower age-related mortality. The relative risk of
stroke was found to be less than one-sixth in men who exercised vigorously
compared with those who were inactive; the risk of type 2 diabetes mellitus was
about half among men who exercised five or more times weekly compared with those
who exercised once a week. Glucose control is improved in diabetics who exercise
regularly, even at a modest level. In sedentary individuals with dyslipidemia,
high amounts of high-intensity exercise produce significant beneficial effects
on serum lipoprotein profiles. Physical activity is associated with a lower risk
of colon cancer (although not rectal cancer) in men and women and of breast and
reproductive organ cancer in women. Finally, weight-bearing exercise (especially
resistance and high-impact activities) increases bone mineral content and
retards development of osteoporosis in women and contributes to a reduced risk
of falls in older persons. Resistance training has been shown to enhance
muscular strength, functional capacity, and quality of life in men and women
with and without CHD and is endorsed by the American Heart Association.<br /></div>
<a href="" name="50"></a>
<div class="contentBody">
Exercise may also confer benefits on those with chronic
illness. Men and women with chronic symptomatic osteoarthritis of one or both
knees benefited from a supervised walking program, with improved self-reported
functional status and decreased pain and use of pain medication. Exercise
produces sustained lowering of both systolic and diastolic blood pressure in
patients with mild hypertension. In addition, physical activity can help
patients maintain ideal body weight. Individuals who maintain ideal body weight
have a 35–55% lower risk for myocardial infarction than with those who are
obese. Physical activity reduces depression and anxiety; improves adaptation to
stress; improves sleep quality; and enhances mood, self-esteem, and overall
performance. <br /></div>
<a href="" name="774852"></a>
<div class="contentBody">
In longitudinal cohort studies, individuals who report
higher levels of leisure time physical activity are less likely to gain weight.
Conversely, individuals who are overweight are less likely to stay active.
However, at least 60 minutes of daily moderate-intensity physical activity may
be necessary to maximize weight loss and prevent significant weight regain.
Moreover, adequate levels of physical activity appear to be important for the
prevention of weight gain and the development of obesity. Physical activity also
appears to have an independent effect on health-related outcomes such as
development of type 2 diabetes mellitus in patients with impaired glucose
tolerance when compared with body weight, suggesting that adequate levels of
activity may counteract the negative influence of body weight on health
outcomes. <br /></div>
<a href="" name="51"></a>
<div class="contentBody">
However, physical exertion can rarely trigger the onset of
acute myocardial infarction, particularly in persons who are habitually
sedentary. Increased activity increases the risk of musculoskeletal injuries,
which can be minimized by proper warm-up and stretching, and by gradual rather
than sudden increase in activity. Other potential complications of exercise
include angina pectoris, arrhythmias, sudden death, and asthma. In
insulin-requiring diabetics who undertake vigorous exercise, the need for
insulin is reduced; hypoglycemia may be a consequence. <br /></div>
<a href="" name="52"></a>
<div class="contentBody">
Only about 20% of adults in the United States are active at
the moderate level—and only 8% currently exercise at the more vigorous
level—recommended for health benefits. Instead, 60% report irregular or no
leisure time physical activity. <br /></div>
<a href="" name="53"></a>
<div class="contentBody">
The value of routine electrocardiography stress testing
prior to initiation of an exercise program in middle-aged or older adults
remains controversial. Patients with ischemic heart disease or other
cardiovascular disease require medically supervised, graded exercise programs.
Medically supervised exercise prolongs life in patients with congestive heart
failure. Exercise should not be prescribed for patients with decompensated
congestive heart failure, complex ventricular arrhythmias, unstable angina
pectoris, hemodynamically significant aortic stenosis, or significant aortic
aneurysm. Five- to 10-minute warm-up and cool-down periods, stretching
exercises, and gradual increases in exercise intensity help prevent
musculoskeletal and cardiovascular complications. <br /></div>
<a href="" name="54"></a>
<div class="contentBody">
Physical activity can be incorporated into any person's
daily routine. For example, the clinician can advise a patient to take the
stairs instead of the elevator, to walk or bike instead of driving, to do
housework or yard work, to get off the bus one or two stops earlier and walk the
rest of the way, to park at the far end of the parking lot, or to walk during
the lunch hour. The basic message should be the more the better and anything is
better than nothing. <br /></div>
<a href="" name="774853"></a>
<div class="contentBody">
To be more effective in counseling about exercise,
clinicians can also incorporate motivational interviewing techniques, adopt a
whole practice approach (eg, use practice nurses to assist), and establish
linkages with community agencies. Clinicians can incorporate the "5 As"
approach: </div>
<dl class="font12">
<dd class="font12List"><b>1. Ask (identify those who can benefit).
</b></dd><dd class="font12List"><b>2. Assess (current activity level).
</b></dd><dd class="font12List"><b>3. Advise (individualize plan).
</b></dd><dd class="font12List"><b>4. Assist (provide a written exercise prescription and
support material).
</b></dd><dd class="font12List"><b>5. Arrange (appropriate referral and follow
up).</b></dd></dl>
<a href="" name="776248"></a>
<div class="contentBody">
Such interventions have a moderate effect on self-reported
physical activity and cardiorespiratory fitness, even if they do not always help
patients achieve a predetermined level of physical activity. In their
counseling, clinicians should advise patients about both the benefits and risks
of exercise, prescribe an exercise program appropriate for each patient, and
provide advice to help prevent injuries or cardiovascular complications. </div>
<a href="" name="776249"></a>
<div class="contentBody">
Although primary care providers regularly ask patients
about physical activity and advise them with verbal counseling, few providers
provide written prescriptions or perform fitness assessments. Tailored
interventions may potentially help increase physical activity in individuals.
Exercise counseling with a prescription, eg, for walking at either a hard
intensity or a moderate intensity-high frequency, can produce significant
long-term improvements in cardiorespiratory fitness. To be effective, exercise
prescriptions must include recommendations on type, frequency, intensity, time,
and progression of exercise and must follow disease-specific guidelines. In
addition, published research suggests that getting patients to change physical
activity levels requires motivational strategies beyond simple exercise
instruction including patient education about goal-setting, self-monitoring, and
problem-solving. For example, helping patients identify emotionally rewarding
and physically appropriate activities, meet contingencies, and find social
support will increase rates of exercise continuation.<br /></div>
<a href="" name="776250"></a>
<div class="contentBody">
Some physical activity is always preferable to a sedentary
lifestyle. For home-bound elderly who have limited mobility and strength, such
physical activity could focus on "functional fitness," such as mobility,
transfers, and performing activities of daily living. Exercise-based
rehabilitation can protect against falls and fall-related injuries and improve
functional performance.</div>
</div>Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0tag:blogger.com,1999:blog-9140290118247641778.post-45354666068751768312012-06-20T12:20:00.000-07:002012-06-20T12:20:12.100-07:00Osteoporosis Prevention<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-size: x-large;"><b>Prevention of Osteoporosis :</b></span><br /><br /><div class="contentBody">
Osteoporosis, characterized by low bone mineral density, is
common and associated with an increased risk of fracture. The lifetime risk of
an osteoporotic fracture is approximately 50% for women and 30% for men.
Osteoporotic fractures can cause significant pain and disability. As such,
research has focused on means of preventing osteoporosis and related fractures.
Primary prevention strategies include calcium supplementation, vitamin D
supplementation, and exercise programs. A recent systematic review and
meta-analysis found that calcium supplementation of 1200 mg per day or more
(with or without vitamin D) could decrease fracture risk for adults (mainly
women were studied) over age 50. Screening for osteoporosis on the basis of low
bone mineral density is also recommended for women over age 60, based on
indirect evidence that screening can identify women with low bone mineral
density and that treatment of women with low bone density with bisphosphonates
is effective in reducing fractures. The effectiveness of screening for
osteoporosis in younger women and in men has not been established. In addition,
real-world adherence to pharmacologic therapy for osteoporosis is low: one-third
to one-half of patients do not take their medication as directed. Vitamin D
deficiency is common and can increase the risk of fracture. Screening to detect
vitamin D deficiency in older adults has been proposed, but has not yet been
rigorously evaluated.</div>
</div>Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0tag:blogger.com,1999:blog-9140290118247641778.post-39549984590995798692012-06-14T10:08:00.000-07:002012-06-14T10:08:27.093-07:00Chemoprevention<div dir="ltr" style="text-align: left;" trbidi="on">
<b><span style="font-size: x-large;">Chemo :</span></b><br />As discussed in Heart Disease and Nervous System Disorders, regular use of low-dose aspirin (81–325 mg) can reduce the incidence of myocardial infarction in men. Low-dose aspirin reduces stroke but not myocardial infarction in middle-aged women. Based on its ability to prevent cardiovascular events, aspirin use is cost-effective for men and women who are at increased risk. Nonsteroidal anti-inflammatory drugs may reduce the incidence of colorectal adenomas and polyps but may also increase heart disease and gastrointestinal bleeding, and thus are not recommended for colon cancer prevention in average risk patients. Antioxidant vitamin (vitamin E, vitamin C, and beta-carotene) supplementation produced no significant reductions in the 5-year incidence of—or mortality from—vascular disease, cancer, or other major outcomes in high-risk individuals with coronary artery disease, other occlusive arterial disease, or diabetes mellitus.</div>Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0tag:blogger.com,1999:blog-9140290118247641778.post-49582856254755983012012-06-04T08:17:00.001-07:002012-06-04T08:17:41.955-07:00Smoking Treatments<div dir="ltr" style="text-align: left;" trbidi="on">
Smoking Treatment :<br /><br />
<table bgcolor="#ffffff" border="0" cellpadding="0" cellspacing="0"><tbody>
<tr>
<td bgcolor="#cccccc" style="border-left: rgb(102,102,102) 1px solid; border-right: rgb(102,102,102) 1px solid; border-top: rgb(102,102,102) 1px solid;"><table border="0" cellpadding="3" cellspacing="0">
<tbody>
<tr>
<td>
<div class="tableTitle">
Smoking Treatments.</div>
</td></tr>
</tbody></table>
</td></tr>
<tr>
<td>
<table bgcolor="#666666" border="0" cellpadding="3" cellspacing="1">
<colgroup span="2"></colgroup>
<thead>
<tr class="font12">
<th align="left" bgcolor="#ffffff" valign="top">Component</th>
<th align="left" bgcolor="#ffffff" valign="top">Examples</th></tr>
</thead>
<tbody>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="3" valign="top">Encouragement
of the patient in the quit attempt </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Note that effective
cessation treatments are now available. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Note that half the people
who have <i>ever</i> smoked have now quit. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Communicate belief in the
patient's ability to quit. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="3" valign="top">Communication
of caring and concern </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Ask how the patient feels
about quitting.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Directly express concern
and a willingness to help. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Be open to the patient's
expression of fears of quitting, difficulties experienced, and ambivalent
feelings. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="5" valign="top">Encouragement
of the patient to talk about the quitting process</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Ask about </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> Reasons that the
patient wants to quit. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> Difficulties
encountered while quitting. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> Success the patient has
achieved. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> Concerns or worries
about quitting.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="4" valign="top">Provision of
basic information about smoking and successful quitting </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Inform the patient about
</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> The nature and time
course of withdrawal. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> The addictive nature of
smoking. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> The fact that any
smoking (even a single puff) increases the likelihood of full relapse. </td></tr>
</tbody></table>
</td></tr>
</tbody></table>
<br /><table bgcolor="#ffffff" border="0" cellpadding="0" cellspacing="0"><tbody>
<tr><td bgcolor="#cccccc" style="border-left: rgb(102,102,102) 1px solid; border-right: rgb(102,102,102) 1px solid; border-top: rgb(102,102,102) 1px solid;"><table border="0" cellpadding="3" cellspacing="0"><tbody>
<tr><td><div class="tableTitle">
Clinical Guidelines For Prescribing Nicotine Replacement Products.</div>
</td></tr>
</tbody></table>
</td></tr>
<tr>
<td>
<table bgcolor="#666666" border="0" cellpadding="3" cellspacing="1">
<colgroup></colgroup>
<tbody>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><b>1. Who should receive
nicotine replacement therapy?</b> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> Available research
shows that nicotine replacement therapy generally increases rates of smoking
cessation. Therefore, except in special circumstances, the clinician should
encourage the use of nicotine replacement with patients who smoke. Little
research is available on the use of nicotine replacement with light smokers (ie,
those smoking <img src="" /> 10–15
cigarettes/d). If nicotine replacement is to be used with light smokers, a lower
starting dose of the nicotine patch or nicotine gum should be
considered.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><b>2. Should nicotine
replacement therapy be tailored to the individual smoker?</b> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> Research does not
support the tailoring of nicotine patch therapy (except with light smokers as
noted above). Patients should be prescribed the patch dosages outlined in Table .</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> Research supports
tailoring nicotine gum treatment. Specifically, research suggests that 4-mg gum
rather than 2-mg gum be used with patients who are highly dependent on nicotine
(eg, those smoking > 20 cigarettes/d, those who smoke immediately upon
awakening, and those who report histories of severe nicotine withdrawal
symptoms). Clinicians may also recommend the higher gum dose if patients request
it or have failed to quit using the 2-mg gum.</td></tr>
</tbody></table>
</td></tr>
</tbody></table>
<br /><table bgcolor="#ffffff" border="0" cellpadding="0" cellspacing="0"><tbody>
<tr>
<td bgcolor="#cccccc" style="border-left: rgb(102,102,102) 1px solid; border-right: rgb(102,102,102) 1px solid; border-top: rgb(102,102,102) 1px solid;"><table border="0" cellpadding="3" cellspacing="0">
<tbody>
<tr>
<td>
<div class="tableTitle">
Suggestions For The Clinical Use Of The Nicotine Patch.</div>
</td></tr>
</tbody></table>
</td></tr>
<tr>
<td>
<table bgcolor="#666666" border="0" cellpadding="3" cellspacing="1">
<colgroup span="4"></colgroup>
<thead>
<tr class="font12">
<th align="left" bgcolor="#ffffff" valign="top">Parameter of Clinical Use</th>
<th align="left" bgcolor="#ffffff" colspan="3" valign="top">Suggestions</th></tr>
</thead>
<tbody>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Patient selection</td>
<td align="left" bgcolor="#ffffff" class="font12" colspan="3" valign="top">Appropriate as
a primary pharmacotherapy for smoking cessation.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="3" valign="top">Precautions</td>
<td align="left" bgcolor="#ffffff" class="font12" colspan="3" valign="top"><i>Pregnancy:</i> Pregnant smokers should first be encouraged to
attempt cessation without pharmacologic treatment. The nicotine patch should be
used during pregnancy only if the increased likelihood of smoking cessation,
with its potential benefits, outweighs the risk of nicotine replacement and
potential concomitant smoking. Similar factors should be considered in lactating
women.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" colspan="3" valign="top"><i>Cardiovascular diseases:</i> While not an independent risk factor
for acute myocardial events, the nicotine patch should be used only after
consideration of risks and benefits among particular cardiovascular patient
groups: those in the immediate (within 2 weeks) post-myocardial infarction
period, those with serious arrhythmias, and those with severe or worsening
angina pectoris.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" colspan="3" valign="top"><i>Skin
reactions:</i> Up to 50% of patients using the nicotine patch will have a local
skin reaction. Skin reactions are usually mild and self-limiting but may worsen
over the course of therapy. Local treatment with hydrocortisone cream (2.5%) or
triamcinolone cream (0.5%) and rotating patch sites may ameliorate such local
reactions. In fewer than 5% of patients do such reactions require the
discontinuation of nicotine patch treatment.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="10" valign="top">Dosage<sup>1</sup><br /> </td>
<td align="left" bgcolor="#ffffff" class="font12" colspan="3" valign="top">Treatment of 8
weeks or less has been shown to be as efficacious as longer treatment periods.
Based on this finding, we suggest the following treatment schedules as
reasonable for most smokers. Clinicians should consult the package insert for
other treatment suggestions. Finally, clinicians should consider individualizing
treatment based on specific patient characteristics such as previous experience
with the patch, number of cigarettes smoked, and degree of addiction.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><b>Brand</b> </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><b>Duration
(weeks)</b> </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><b>Dosage
(mg/h)</b> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="3" valign="top">Nicoderm and
Habitrol</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">4</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">21/24</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">then 2</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">14/24</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">then 2</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">7/24</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="2" valign="top">Prostep</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">4</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">22/24</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">then 4</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">11/24</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="3" valign="top">Nicotrol</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">4</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">15/16</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">then 2</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">10/16</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">then 2</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">5/16</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="4" valign="top">Prescribing
instructions</td>
<td align="left" bgcolor="#ffffff" class="font12" colspan="3" valign="top"><i>Abstinence
from smoking:</i> The patient should refrain from smoking while using the patch.
</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" colspan="3" valign="top"><i>Location:</i> At the start of each day, the patient should place a
new patch on a relatively hairless location between the neck and the
waist. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" colspan="3" valign="top"><i>Activities:
</i>There are no restrictions while using the patch. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" colspan="3" valign="top"><i>Time:</i>
Patches should be applied as soon as patients awaken on their quit day. </td></tr>
</tbody></table>
</td></tr>
</tbody></table>
<br /><table bgcolor="#ffffff" border="0" cellpadding="0" cellspacing="0"><tbody>
<tr>
<td bgcolor="#cccccc" style="border-left: rgb(102,102,102) 1px solid; border-right: rgb(102,102,102) 1px solid; border-top: rgb(102,102,102) 1px solid;"><table border="0" cellpadding="3" cellspacing="0">
<tbody>
<tr>
<td>
<div class="tableTitle">
Suggestions For The Clinical Use Of Nicotine Gum.</div>
</td></tr>
</tbody></table>
</td></tr>
<tr>
<td>
<table bgcolor="#666666" border="0" cellpadding="3" cellspacing="1">
<colgroup span="2"></colgroup>
<thead>
<tr class="font12">
<th align="left" bgcolor="#ffffff" valign="top">Parameter of Clinical Use </th>
<th align="left" bgcolor="#ffffff" valign="top">Suggestions </th></tr>
</thead>
<tbody>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Patient selection</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Appropriate as a primary
pharmacotherapy for smoking cessation.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="3" valign="top">Precautions</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Pregnancy:</i>
Pregnant smokers should first be encouraged to attempt cessation without
pharmacologic treatment. Nicotine gum should be used during pregnancy only if
the increased likelihood of smoking cessation, with its potential benefits,
outweighs the risk of nicotine replacement and potential concomitant
smoking.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Cardiovascular
diseases</i>: Although not an independent risk factor for acute myocardial
events, nicotine gum should be used only after consideration of risks and
benefits among particular cardiovascular patient groups: those in the immediate
(within 2 weeks) post-myocardial infarction period, those with serious
arrhythmias, and those with serious or worsening angina pectoris. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Adverse effects:</i>
Common adverse effects of nicotine chewing gum include mouth soreness, hiccups,
dyspepsia, and jaw ache. These effects are generally mild and transient and can
often be alleviated by correcting the patient's chewing technique (see
"Prescribing instructions" below).</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Dosage</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Dosage:</i> Nicotine
gum is available in doses of 2 mg and 4 mg per piece. Patients who smoke less
than 25 cigarettes per day should be prescribed the 2-mg gum initially. The 4-mg
gum should be prescribed to patients who express a preference for it, have
failed with the 2-mg gum but remain motivated to quit, and/or smoke more than 25
cigarettes per day. The gum is most commonly prescribed for the first few months
of a quit attempt. Clinicians should tailor the duration of therapy to fit the
needs of each patient. Patients using the 2-mg strength should use not more than
30 pieces per day, whereas those using the 4-mg strength should not exceed 20
pieces per day. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="4" valign="top">Prescribing
instructions </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Abstinence from
smoking:</i> The patient should refrain from smoking while using the gum.
</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Chewing technique:</i>
The gum should be chewed slowly until a "peppery" taste emerges, then "parked"
between cheek and gum to facilitate nicotine absorption through the oral mucosa.
Gum should be slowly and intermittently chewed and parked for about 30 minutes.
</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Absorption:</i> Acidic
beverages (eg, coffee, juices, soft drinks) interfere with the buccal absorption
of nicotine, so eating and drinking anything except water should be avoided for
15 minutes before and during chewing. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Scheduling of
dose:</i> A common problem is that patients do not use enough gum to get the
maximum benefit: they chew too few pieces per day and do not use the gum for a
sufficient number of weeks. Instructions to chew the gum on a fixed schedule (at
least 1 piece every 1 to 2 hours) for at least 1 to 3 months may be more
beneficial than ad lib use. </td></tr>
</tbody></table>
</td></tr>
</tbody></table>
<br /><table bgcolor="#ffffff" border="0" cellpadding="0" cellspacing="0"><tbody>
<tr>
<td bgcolor="#cccccc" style="border-left: rgb(102,102,102) 1px solid; border-right: rgb(102,102,102) 1px solid; border-top: rgb(102,102,102) 1px solid;">
<table border="0" cellpadding="3" cellspacing="0">
<tbody>
<tr>
<td>
<div class="tableTitle">
Suggestions For The Clinical Use Of Bupropion SR.</div>
</td></tr>
</tbody></table>
</td></tr>
<tr>
<td>
<table bgcolor="#666666" border="0" cellpadding="3" cellspacing="1">
<colgroup span="2"></colgroup>
<thead>
<tr class="font12">
<th align="left" bgcolor="#ffffff" valign="top">Parameter of Clinical Use</th>
<th align="left" bgcolor="#ffffff" valign="top">Suggestions</th></tr>
</thead>
<tbody>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Patient selection</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Appropriate as a
first-line pharmacotherapy for smoking cessation.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="4" valign="top">Precautions</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Pregnancy:</i>
Pregnant smokers should be encouraged to quit first without pharmacologic
treatment. Bupropion SR should be used during pregnancy only if the increased
likelihood of smoking abstinence, with its potential benefits, outweighs the
risk of bupropion SR treatment and potential concomitant smoking. Similar
factors should be considered in lactating women (FDA Class B).</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Cardiovascular
diseases:</i> Generally well tolerated; infrequent reports of
hypertension. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Side effects:</i> The
most common side effects reported by bupropion SR users were insomnia (35–40%)
and dry mouth (10%). </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Contraindications:</i> Bupropion SR is contraindicated in
individuals with a history of seizure disorder, a history of an eating disorder,
who are using another form of bupropion (Wellbutrin or Wellbutrin SR), or who
have used an MAO inhibitor in the past 14 days.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Dosage</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Patients should begin
with a dose of 150 mg every morning for 3 days, then increase to 150 mg twice
daily. Dosing at 150 mg twice daily should continue for 7–12 weeks following the
quit date. Unlike nicotine replacement products, patients should begin bupropion
SR treatment 1–2 weeks before they quit smoking. For maintenance therapy,
consider bupropion SR 150 mg twice daily for up to 6 months.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="3" valign="top">Prescribing
instructions </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Cessation prior to
quit date:</i> Recognize that some patients will lose their desire to smoke
prior to their quit date, or will spontaneously reduce the amount they
smoke. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Scheduling of
dose:</i> If insomnia is marked, taking the evening dose earlier (in the
afternoon, at least 8 hours after the first dose) may provide some
relief. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Alcohol:</i> Use
alcohol only in moderation. </td></tr>
</tbody></table>
</td></tr>
</tbody></table>
</div>Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0tag:blogger.com,1999:blog-9140290118247641778.post-65394161242986194232012-05-25T10:37:00.001-07:002012-05-25T10:37:47.087-07:00Cigarette Smoking<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: center;">
<span style="font-size: x-large;"><b>Cigarette smoking
</b></span></div>
<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh21Ait8nIv8mHon75d99zVL9YywJk63pNCmAVZwDhKOppg2FnPoA6Bcx7JftAkaGPs3k1rLILv00yyaL7EhyvecmZMbo1nk3RXQhSbb1wACOlZI9AGGmXhvW9fd3eJ7RnGkrsfWundA3I/s1600/smoking.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh21Ait8nIv8mHon75d99zVL9YywJk63pNCmAVZwDhKOppg2FnPoA6Bcx7JftAkaGPs3k1rLILv00yyaL7EhyvecmZMbo1nk3RXQhSbb1wACOlZI9AGGmXhvW9fd3eJ7RnGkrsfWundA3I/s320/smoking.jpg" width="320" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
</div>
<div class="separator" style="clear: both;">
</div>
<div class="contentBody">
Cigarette smoking remains the most important cause of
preventable morbidity and early mortality. In 2000, there were an estimated 4.8
million premature deaths in the world attributable to smoking, 2.4 million in
developing countries and 2 million in industrialized countries. More than
three-quarters (3.8 million) of these deaths were in men. The leading causes of
death from smoking were cardiovascular diseases (1.7 million deaths), chronic
obstructive pulmonary disease (COPD) (1 million deaths), and lung cancer (0.9
million deaths). Nicotine is highly addictive, raises brain levels of dopamine,
and produces withdrawal symptoms on discontinuation. Cigar smoking has also
increased; there is also continued use of smokeless tobacco (chewing tobacco and
snuff), particularly among young people. Tobacco dependence may have a genetic
component. </div>
<a href="http://www.blogger.com/blogger.g?blogID=9140290118247641778" name="779265"></a>
<br />
<div class="contentBody">
Cigarettes are responsible for one in every five deaths in
the United States, yet smoking prevalence rates have been increasing among high
school and college students. Currently, 23% of US adults and 26% of US young
adults are smokers.</div>
<a href="http://www.blogger.com/blogger.g?blogID=9140290118247641778" name="25"></a>
<br />
<div class="contentBody">
Smokers have twice the risk of fatal heart disease, 10
times the risk of lung cancer, and several times the risk of cancers of the
mouth, throat, esophagus, pancreas, kidney, bladder, and cervix; a twofold to
threefold higher incidence of stroke and peptic ulcers (which heal less well
than in nonsmokers); a twofold to fourfold greater risk of fractures of the hip,
wrist, and vertebrae; four times the risk of invasive pneumococcal disease; and
a twofold increase in cataracts. In the United States, over 90% of cases of COPD
occur among current or former smokers. Both active smoking and passive smoking
are associated with deterioration of the elastic properties of the aorta
(increasing the risk of aortic aneurysm) and with progression of carotid artery
atherosclerosis. Smoking has also been associated with increased risks of
leukemia, of colon and prostate cancers, of breast cancer among postmenopausal
women who are slow acetylators of <i>N</i>-acetyltransferase-2 enzymes,
osteoporosis, and Alzheimer's disease. In cancers of the head and neck, lung,
esophagus, and bladder, smoking is linked to mutations of the <i>P53</i> gene,
the most common genetic change in human cancer. Patients with head and neck
cancer who continue to smoke during radiation therapy have lower rates of
response than those who do not smoke. Olfaction and taste are impaired in
smokers, and facial wrinkles are increased. Heavy smokers have a 2.5 greater
risk of age-related macular degeneration. Smokers die 5–8 years earlier than
never-smokers.</div>
<a href="http://www.blogger.com/blogger.g?blogID=9140290118247641778" name="23691"></a>
<br />
<div class="contentBody">
The children of smokers have lower birth weights, are more
likely to be mentally retarded, have more frequent respiratory infections and
less efficient pulmonary function, have a higher incidence of chronic ear
infections than children of nonsmokers, and are more likely to become smokers
themselves.</div>
<a href="http://www.blogger.com/blogger.g?blogID=9140290118247641778" name="23692"></a>
<br />
<div class="contentBody">
In addition, exposure to environmental tobacco smoke has
been shown to increase the risk of cervical cancer, lung cancer, invasive
pneumococcal disease, and heart disease; to promote endothelial damage and
platelet aggregation; and to increase urinary excretion of tobacco-specific lung
carcinogens. The incidence of breast cancer may be increased as well. Of
approximately 450,000 smoking-related deaths in the United States annually, as
many as 53,000 are attributable to environmental tobacco smoke.</div>
<a href="http://www.blogger.com/blogger.g?blogID=9140290118247641778" name="23693"></a>
<br />
<div class="contentBody">
Smoking cessation reduces the risks of death and of
myocardial infarction in people with coronary artery disease; reduces the rate
of death and acute myocardial infarction in patients who have undergone
percutaneous coronary revascularization; lessens the risk of stroke; slows the
rate of progression of carotid atherosclerosis; and is associated with
improvement of COPD symptoms. On average, women smokers who quit smoking by age
35 add about 3 years to their life expectancy, and men add more than 2 years to
theirs. Smoking cessation can increase life expectancy even for those who stop
after the age of 65. </div>
<div class="contentBody">
Although tobacco use constitutes the most serious common
medical problem, it is undertreated. Almost 40% of smokers attempt to quit each
year, but only 4% are successful. Factors associated with successful cessation
include having a rule against smoking in the home, being older, and having
greater education. Persons whose physicians advise them to quit are 1.6 times as
likely to attempt quitting. Over 70% of smokers see a physician each year, but
only 20% of them receive any medical quitting advice or assistance.</div>
<div class="contentBody">
<br /></div>
<div class="contentBody">
Several effective interventions are available to promote smoking cessation,
including counseling, pharmacotherapy, and combinations of the two. The five
steps for helping smokers quit are summarized in Table 1–3. Common elements of
supportive smoking cessation treatments are reviewed in Table 1–4. A system
should be implemented to identify smokers, and advice to quit should be tailored
to the patient's level of readiness to change. Pharmacotherapy to reduce
cigarette consumption is ineffective in smokers who are unwilling or not ready
to quit. Conversely, all patients trying to quit should be offered
pharmacotherapy except those with medical contraindications, women who are
pregnant or breast-feeding, and adolescents.</div>
<div class="contentBody">
<br /></div>
<table bgcolor="#ffffff" border="0" cellpadding="0" cellspacing="0"><tbody>
<tr>
<td bgcolor="#cccccc" style="border-left: rgb(102,102,102) 1px solid; border-right: rgb(102,102,102) 1px solid; border-top: rgb(102,102,102) 1px solid;"><table border="0" cellpadding="3" cellspacing="0">
<tbody>
<tr>
<td><div class="tableTitle">
Actions and strategies for the primary care
clinician to help patients quit smoking.</div>
</td></tr>
</tbody></table>
</td></tr>
<tr>
<td><table bgcolor="#666666" border="0" cellpadding="3" cellspacing="1">
<colgroup span="2"></colgroup>
<thead>
<tr class="font12">
<th align="left" bgcolor="#ffffff" valign="top">Action</th>
<th align="left" bgcolor="#ffffff" valign="top">Strategies for
Implementation</th></tr>
</thead>
<tbody>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" colspan="2" valign="top"><i><b>Step 1.
Ask—Systematically Identify All Tobacco Users at Every Visit</b></i> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="4" valign="top">Implement an
officewide system that ensures that for <i>every</i> patient at <i>every</i>
clinic visit, tobacco-use status is queried and documented<sup>1</sup><br />
</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Expand the vital signs to
include tobacco use. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> Data should be
collected by the health care team. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> The action should be
implemented using preprinted progress note paper that includes the expanded
vital signs, a vital signs stamp or, for computerized records, an item assessing
tobacco-use status.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Alternatives to the vital
signs stamp are to place tobacco-use status stickers on all patients' charts or
to indicate smoking status using computerized reminder systems.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" colspan="2" valign="top"><i><b>Step 2.
Advise—Strongly Urge All Smokers to Quit</b></i> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="5" valign="top">In a <i>clear,
strong,</i> and <i>personalized</i> manner, urge every smoker to quit </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Advice should
be</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> <i><b>Clear:</b></i>"I
think it is important for you to quit smoking now, and I will help you. Cutting
down while you are ill is not enough." </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> <i><b>Strong:</b></i>"As your clinician, I need you to know
that quitting smoking is the most important thing you can do to protect your
current and future health." </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> <i><b>
Personalized:</b></i> Tie smoking to current health or illness and/or the social
and economic costs of tobacco use, motivational level/readiness to quit, and the
impact of smoking on children and others in the household. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Encourage clinic staff to
reinforce the cessation message and support the patient's quit
attempt.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" colspan="2" valign="top"><i><b>Step 3.
Attempt—Identify Smokers Willing to Make a Quit Attempt</b></i> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="3" valign="top">Ask every
smoker if he or she is willing to make a quit attempt at this time</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">If the patient is willing
to make a quit attempt at this time, provide assistance (see step 4). </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">If the patient prefers a
more intensive treatment or the clinician believes more intensive treatment is
appropriate, refer the patient to interventions administered by a smoking
cessation specialist and follow up with him or her regarding quitting (see step
5). </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">If the patient clearly
states he or she is not willing to make a quit attempt at this time, provide a
motivational intervention.</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" colspan="2" valign="top"><i><b>Step 4.
Assist—Aid the Patient in Quitting</b></i> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="6" valign="top">A. Help the
patient with a quit plan</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Set a quit date.</i>
Ideally, the quit date should be within 2 weeks, taking patient preference into
account. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i>Help the patient
prepare for quitting.</i> The patient must: </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> <i>Inform</i> family,
friends, and coworkers of quitting and request understanding and support.
</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> <i>Prepare the
environment</i> by removing cigarettes from it. Prior to quitting, the patient
should avoid smoking in places where he or she spends a lot of time (eg, home,
car). </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> <i>Review</i> previous
quit attempts. What helped? What led to relapse? </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"> <i>Anticipate</i>
challenges to the planned quit attempt, particularly during the critical first
few weeks. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top">B. Encourage nicotine
replacement therapy except in special circumstances</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top">Encourage the use of the
nicotine patch or nicotine gum therapy for smoking cessation (see Table 1–5,
Table 1–6, and Table 1–7 for specific instructions and precautions). </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="3" valign="top">C. Give key
advice on successful quitting </td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i><b>Abstinence:</b></i>
Total abstinence is essential. Not even a single puff after the quit date.
</td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i><b>Alcohol:</b></i>
Drinking alcohol is highly associated with relapse. Those who stop smoking
should review their alcohol use and consider limiting or abstaining from alcohol
use during the quit process. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i><b>Other smokers in
the household:</b></i> The presence of other smokers in the household,
particularly a spouse, is associated with lower success rates. Patients should
consider quitting with their significant others and/or developing specific plans
to maintain abstinence in a household where others still smoke. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="3" valign="top">D. Provide
supplementary materials</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i><b>Source:</b></i>
Federal agencies, including the National Cancer Institute and the Agency for
Health Care Policy and Research; nonprofit agencies (American Cancer Society,
American Lung Association, American Heart Association); or local or state health
departments. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i><b>Selection
concerns:</b></i> The material must be culturally, racially, educationally, and
age appropriate for the patient. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i><b>Location:</b></i>
Readily available in every clinic office. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" colspan="2" valign="top"><i><b>Step 5.
Arrange—Schedule Follow-Up Contact</b></i> </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" rowspan="2" valign="top">Schedule
follow-up contact, either in person or via telephone<sup>1</sup><br />
</td>
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i><b>Timing:</b></i>
Follow-up contact should occur soon after the quit date, preferably during the
first week. A second follow-up contact is recommended within the first month.
Schedule further follow-up contacts as indicated. </td></tr>
<tr class="font12">
<td align="left" bgcolor="#ffffff" class="font12" valign="top"><i><b>Actions during
follow-up:</b></i> Congratulate success. If smoking occurred, review the
circumstances and elicit recommitment to total abstinence. Remind the patient
that a lapse can be used as a learning experience and is not a sign of failure.
Identify the problems already encountered and anticipate challenges in the
immediate future. Assess nicotine replacement therapy use and problems. Consider
referral to a more intense or specialized
program.</td></tr>
</tbody></table>
</td></tr>
<tr>
<td bgcolor="#ffffff"><br />
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<span class="font11" style="font-size: x-small;">
</span></td></tr>
</tbody></table>
<br />
<div>
<br /></div>
<div>
<br /></div>
<br />
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</div>Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0tag:blogger.com,1999:blog-9140290118247641778.post-39399322628180596792012-05-17T05:41:00.000-07:002012-05-17T05:41:49.816-07:00Abdominal Aortic Aneurysm<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-size: x-large;"><b>Abdominal Aortic Aneurysm : </b></span><br />Screening for abdominal aortic aneurysm in men aged 65-75 years is associated with a significant reduction in condition-specific mortality (odds ratio, 0.57 [95% CI, 0.45 to 0.74]). This benefit is sustained through 7 years of followup. Women do not appear to benefit, and the most of the benefit in men appears to accrue among current or former smokers.</div>Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0tag:blogger.com,1999:blog-9140290118247641778.post-82509676520212963082012-05-11T11:58:00.000-07:002012-05-11T11:58:46.295-07:00Cardiovascular Disease prevention<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-size: x-large;"><b>Cardiovascular Disease :</b></span><br />Cardiovascular diseases, including coronary heart disease (CHD) and stroke, represent two of the most important causes of morbidity and mortality in developed countries.<br />
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Several risk factors increase the risk for coronary disease and stroke. They can be divided into those that are modifiable (eg, lipid disorders, hypertension, cigarette smoking) and those that are not (eg, gender, age, family history of early coronary disease). This section considers the role of screening for and treating modifiable risk factors.<br />
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Impressive declines in age-specific mortality rates from heart disease and stroke have been achieved in all age groups in North America during the past 2 decades. The chief reasons for this favorable trend appear to be modification of risk factors, especially cigarette smoking and hypercholesterolemia, plus more aggressive detection and treatment of hypertension and better care for patients with heart disease. African-Americans appear to have a greater proportion of risk attributable to these key risk factors, suggesting that focusing on better control could help reduce disparities in health outcomes.<br />
</div>Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0tag:blogger.com,1999:blog-9140290118247641778.post-85700669767509000622012-05-06T03:30:00.000-07:002012-05-06T03:30:59.174-07:00Infectious Disease Prevention<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<span style="font-size: x-large;"><b>Infectious Disease :</b></span><br /><br />
Much of the decline in the incidence and fatality rates of infectious diseases is attributable to public health measures—especially immunization, improved sanitation, and better nutrition.<br />
Immunization remains the best means of preventing many infectious diseases. In the United States, childhood immunization has resulted in near elimination of measles, mumps, rubella, poliomyelitis, diphtheria, pertussis, and tetanus. Haemophilus influenzae type b invasive disease has been reduced by more than 9500 since the introduction of the first conjugate vaccines.<br />
However, substantial vaccine-preventable morbidity and mortality continue to occur among adults from vac-cine-preventable diseases, such as hepatitis A, hepatitis B, influenza, and pneumococcal infections. For example, in adults in the United States, there are an estimated 50,000– 70,000 deaths annually from influenza, hepatitis B, and nVasiVe pneumococcal disease. Influenza vaccination is recommended for adults age 50 and older, and it has been documented that annual influenza immunization with Inactivated vaccine (administered intramuscularly) pre¬vents cardiovascular morbidity and all-cause mortality in persons with coronary and other atherosclerotic vascular disease. Rates of influenza vaccination have increased. Self- reported rates of influenza vaccine coverage in adults older than 65 years increased from 300o in 1989 to 70% in 2004. However, vaccination rates were higher for non-Hispanic whites compared with other ethnic minority groups.<br />
The American College of Physicians recommends that clinicians should review each adult's immunization status at age 50; assess risk factors that would indicate a need for pneumococcal vaccination and annual influenza immuni-zations; reimmunize at age 65 those who received an immunization against pneumococcus more than 6 years before; ensure that all adults have completed a primary diphtheria-tetanus immunization series, and administer a single booster at age 50; and assess the postvaccination serologic response to hepatitis B vaccination in all recipi¬ents who have ongoing risks of exposure to blood or body fluids (eg, sharp in)uries, blood splashes).<br />
Strategies have also been proposed to improve influenza, pneumococcal polysaccharide, and hepatitis B vaccination. Strategies to enhance vaccinations in general include increasing community demand for vaccinations; enhancing access to vaccination services; and provider- or system based interventions, such as reminder systems. Increasing reports of pertussis among US adolescents, adults, and their infant contacts have stimulated vaccine development for older age groups. A safe and effective tetanus-diphthena 5- component acellular pertussis vaccine (Tdap) is available for use in adolescents and in adUltS younger than age 65. The Advisory Committee on Immunization Practices (AC.11') I e, int mends routine use 01 a single dose of Tdap for adults aged 19-64 years to replace the next booster dose of tetanus and diphtheria tmoids vaccine (Td). Further research is needed to elucidate the role of vaccination in persons older than 65 years and to determine whether future booster doses of Tdap are needed.<br />
A new recombinant protein hepatitis E vaccine has been developed that has proven safe and efficacious in preventing hepatitis E among high risk populations (such as those in Nepal). Both hepatitis A vaccine and immune globulin provide protection against hepatitis A; however, administration of immune globulin may provide a modest benefit over vaccination in some settings.<br />
Recommended immunization schedules for children and adolescents and adults are set forth in Tables 30-12 and 30-13. Thimerosal-free hepatitis B vaccination is available for newborns and infants, and despite the dis¬proved relationship between vaccines and autism, thime¬rosal-free vaccines are available for pregnant women.<br />
Human papillomavirus (HPV) virus-like particle (VLP) vaccines have demonstrated effectiveness in preventing per¬sistent HPV infections, and thus may impact the rate of cervical intraepithelial neoplasia (CIN) 11-11I. The Ameri¬can Cancer Society and the American Academy of Pediat¬rics (AAP) recommends routine HPV vaccination for girls aged 11-12 years. The AAP also recommends that all unvaccinated girls and women ages 13-26 years receive the HPV vaccine. Trials demonstrate efficacy of bivalent HPV (16/18) or quadrivalent HPV (6/11/16/18)L1 virus-like par-ticle vaccines in preventing new HPV infection and cervical lesions but not in women with preexisting infection. It is estimated that routine use of HPV vaccination of females at 11 to 12 years of age and catch-up vaccination of females at age 13-16 (with vaccination of girls age 9 and 10 at the discretion of the physician) could prevent 95% to 100% of CIN and adenocarcinoma in situ, 99% of genital warts and approximately 70% of cervical cancer cases worldwide; thus, the role of HPV testing will need redefinition. Despite the effectiveness of the vaccine, rates of immunization are low. Interventions addressing personal beliefs and system barriers to vaccinations may help address the slow adoption of this vaccine.<br />
Persons traveling to countries where infections are endemic should take precautions described in Chapter 30. Immunization registries—confidential, population-based, computerized information systems that collect vaccination data about all residents of a geographic area—can be used to increase and sustain high vaccination coverage.<br />
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Skin testing for tuberculosis and treating selected patients reduce the risk of reactivation tuberculosis . Two blood tests, which are not confounded by prior BCG (bacille Calmette-Guerin) vaccination, have been developed to detect tuberculosis infection by measur¬ing in vitro T-cell interferon-gamma release in response to two antigens (the enzyme-linked immunospot [ELISPOT], [T-SPOT.TB] and the other, a quatitative ELISA [Quantiferon- TBGlod] test ) . These T-Cell-based assays have an excellent specificity that is higher than tuberculin skin testing in BCG-vaccinated populations. The rate of tuberculosis in thc United States has been declining since 1992, although this decline has slowed in recent years. In 2007 the tuberculosis rate was the lowest recorded since national reporting began in 1953. The Advisory Council for rhe Elimination of Tuberculosis has called for a renewed corn. rnitment to eliminating tuberculosis in the United States, and the Institute of Medicine has published a detailed plan for achieving that goal. Patients with HIV infection are at an especially high risk for tuberculosis, and tuberculosis preventive therapy in the era of HIV will require further work to overcome implementation barriers and to identify optimal duration of preventive therapy and treatment approach for individuals receiving highly active antiretro¬viral therapy (HAART).<br />
Treatment of tuberculosis poses a risk of hepatotoxicity and thus requires close monitoring of liver transaminases. Alanine aminotransferase (ALT) monitoring during the treatment of latent tuberculosis infection is recommended for certain individuals (preexisting liver disease, pregnancy, chronic alcohol consumption). ALT should be monitored in HIV-infected patients during treatment of tuberculosis disease and should be considered in patients over the age of 35. Symptomatic patients with an ALT elevation three times the upper limit of normal (ULN) or asymptomatic patients with an elevation five times the ULN should be treated with a modified or alternative regimen.<br />
HIV infection is now the major infectious disease prob-lem in the world, and it affects 850,000-950,000 persons in the United States. Since sexual contact is a common mode of transmission, primary prevention relies on eliminating unsafe sexual behavior by promoting abstinence, later onset of first sexual activity, decreased number of partners, and use of latex condoms. Appropriately used, condoms can reduce the rate of HIV transmission by nearly 700/0. In one study, couples with one infected partner who used condoms incon¬sistently had a considerable risk of infection: the rate of seroconversion was estimated to be IPA, after 24 months. No seroconversions were noted with consistent condom use Unfortunately, as many as one-third of HIV-positive per¬sons continue unprotected sexual practices after learning that they are HIV-infected. Tailored group educational intervention focused on practicing "safer sex" can red.' their transmission-risk behaviors with partners who are not HIV-positive. Other approaches to prevent HIV infection include treatment of sexually transmitted diseases, develop¬ment of vaginal microbicides, and vaccine developriT. Increasingly, cases of HIV infection are transmitted by 111/e0" tion drug use. HIV prevention activities should include provision of sterile injection equipment for these individuals.<br />
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With regard to secondary prevention, many HIV- infected persons in the United States receive the diagnosis advanced stages of immunosuppression, and almost all will progress to AIDS if untreated. On the other hand. HAAR' substantially reduces the risk of clinical progression or death in patients with advanced immtmosuppression. SreenthrT tests for HIV are extremely (> 99%) Accurate.While the benifits of HIV screening appear to outweigh its harms,current screening is generally based on individual pattient risk factors. Such screening can identify persons at risk for AIDS but misses a substantial proportion of those infected.<br />
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Nonetheless, the yield from screening higher prevalence populations is substantially greater than that from screening the general population, and more widespread screening of the population remains controversial.<br />
In immunocompromised patients, live vaccines are con¬traindicated but many killed or component vaccines are safe and recommended. Asymptomatic HIV infectedpatients have not shown adverse consequences when given live MMR and influenza vaccinations as well as tetanus, hepatitis B, H influenzae type b, and pneumococcal vaccinations—all should be given. However, if poliomyelitis immunization is required, the inactivated poliomyelitis vaccine is indicated. In symptomatic HIV-infected patients, live virus vaccines such as MMR should generally be avoided, but annual influenza vaccination is safe.<br />
Whenever possible, immunizations should be com-pleted before procedures that require or induce immuno¬suppression (organ transplantation or chemotherapy), or that reduce immunogenic responses (splenectomy). How¬ever, if this is not possible, the patient may mount only a partial immune response, yet even this partial response can be beneficial. Patients who undergo allogeneic bone mar¬row transplantation lose preexisting immunities and should be revaccinated. In many situations, family mem¬bers should also be vaccinated to protect the immunocom¬promised patient, although oral live polio vaccine should be avoided because of the risk of infecting the patient.<br />
New cases of poliomyelitis have been reported in the United States, Haiti, and the Dominican Republic recently, slowing its eradication in the Western Hemisphere. Worldwide eradication of poliovirus, including endemic areas such as India, remains challenging.<br />
The current epidemic of highly pathogenic H5N1 avian influenza within duck and poultry populations in Southeast Asia raises serious concerns that genetic reassortment will result in a human influenza pandemic. In 2003 through 2005, there were 138 confirmed cases of human infection with H5N1 avian influenza in Vietnam, Thailand, Indonesia, China, and Cambodia, with a mortality rate of > 50./o. To Prevent and prepare for an increase in human cases, public health officials are working to improve detection methods and to stockpile effective antivirals, such as oseltamivir. The development of an H5N1 vaccine is underway. Two trials have demonstrated development of neutralizing antibodies using a vaccine with varying doses of hemagglutinin antigen.<br />
Herpes zoster, caused by reactivation from previous varicella zoster virus (VZV) infection, affects many older adults and people with immune system dysfunction. Whites are at higher risk than other ethnic groups and the incidence in adults age 65 and older may be higher than previously described. It can cause postherpetic neuralgia, a potentially debilitating chronic pain syndrome. A varicella vaccine is available for the prevention of herpes zoster. Several clinical trials have shown that this vaccine (Zostavax) is safe, elevates VZV-specific cell-mediated immunity, and significantly reduces the incidence of herpes zoster and postherpetic neuralgia in persons older than 60 years. In one randomized, double-blind, placebo-controlled trial among more than 38,000 older adults, the vaccine reduced the incidence of N.herpetic neuralgia by 66% and the incidence of herpes zoster by 51%. The vaccine is administered as a one-time subcutaneous dose (0.65 mL) and is approved for adults 60 years of age and older. However, durability of vaccine response and whether any booster vaccination is needed are still uncertain. The cost effectiveness of the vaccine varies substantially, and the patient's age should be considered in vaccine recommendations. One study reported a cost-effec¬tiveness exceeding $100,000 per quality-adjusted life year saved.<br />
In 2008, the United States Preventive Services Task Force (USPSTF) reviewed evidence to reaffirm its recom-mendation on screening for asymptomatic bacteriuria in adults. New evidence was reviewed, which continues to support routine screening in pregnant women but not in other groups of adults.<br />
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</div>Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0tag:blogger.com,1999:blog-9140290118247641778.post-54262036368365707662012-05-01T10:56:00.000-07:002012-05-01T10:56:51.412-07:00Disease Prevention And Health Maintenance<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-size: x-large;"><b>Disease Prevention And Health Maintenance : </b></span><br />
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Preventive medicine can be categorized as primary, second-ary, or tertiary. Primary prevention aims to remove or reduce disease risk factors (eg, immunization, giving up or not starting smoking). Secondary prevention techniques promote early detection of disease or precursor states (eg, routine cervical Papanicolaou screening to detect carcinoma or dysplasia of the cervix). Tertiary prevention measures are aimed at limiting the impact of established disease (eg, partial mastectomy and radiation therapy to remove and control localized breast cancer). Table 1-1 gives data for deaths from preventable causes in the United States. Table 1-2 compares recommendations for periodic health examinations as developed by the United States Preventive Services Task Force, the American College of Physicians, and the Canadian Task Force on the Periodic Health Examination. Despite emerging consensus on many of the services, controversy persists for others. Many effective preventive services are underutilized. and few adults receive all of the most strongly recommended services. In 2006, the National Commission on Prevention Priorities ranked clinical preventive service recommendations up to December 2004. The three highest-ranking services were discussing aspirin use with high-risk adults, tobacco-use screening and brief interventions, and immunizing children. Other high-ranking services with data indicating low current utilization rates (< 50%) included screening adults aged 50 and older for colorectal cancer, iminunizing adults aged 65 and older against pneumococcal disease' and screening young women for Chlarnydia. Several methods,
including the use of reminder systems or financial incentives, can increase utilization of preventive services, but such methods have not been widely adopted.
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhjONwp_sGm-RcNFsWAkahCxb7Typ48wcRjUpqCKJI8sHGkMmNr6MJitXs24sGrbTPJiT5cJJwt2hS6zRGGUiFQv2j83UArpjelThPkElHUq5GAJjlhCo0mBlrAswQ9nzEChLkm7FVB0M/s1600/preventive-care.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="238" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhjONwp_sGm-RcNFsWAkahCxb7Typ48wcRjUpqCKJI8sHGkMmNr6MJitXs24sGrbTPJiT5cJJwt2hS6zRGGUiFQv2j83UArpjelThPkElHUq5GAJjlhCo0mBlrAswQ9nzEChLkm7FVB0M/s400/preventive-care.JPG" width="400" /></a></div>
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Table: 1-2</div>
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</div>Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0tag:blogger.com,1999:blog-9140290118247641778.post-32027586953384697182012-04-22T12:49:00.001-07:002012-05-01T10:49:17.637-07:00Principles of Care<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-size: x-large;"><b>Guiding Principles :</b></span><br />
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Ethical decisions are often called for in medical practice, at both the "micro" level of the individua patient-clinician relationship and at the "macro" level of the allocation of resources. Ethical principles that guide the successful approach to diagnosis and treatment are honesty, beneficence, justice, avoidance of conflict of interest and the pledge to do no harm. Increasingly, Western medicine involves patients in important decisions about medical care, including how far to proceed with treatment of patients who have terminal illnesses.
The clinician's role does not end with diagnosis and treatment. The importance of the empathic clinician in helping patients and their families bear the burden of serious illness and death cannot be overemphasized. "to cure sometimes, to relieve often, and to comfort always" is a French saying as apt today as it was five centuries ago-- as is French Peabody's admontion:"The secret of the care of the patient is in caring for the patient."<br /><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirStO0WQ4EMAtesE6qyT0cT8cPZVoHF5ARL0qf5DGEC_HV5xyW7YKNNzcvEeB4NsA4SKUtgTaHGMXL4pA_zDkiXeNbI6FavLN9-2_6QA5fqPZjuAicbTUPJOz7dh3W4clREC3JrImsB3I/s1600/estimated-death-annual.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" height="224" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirStO0WQ4EMAtesE6qyT0cT8cPZVoHF5ARL0qf5DGEC_HV5xyW7YKNNzcvEeB4NsA4SKUtgTaHGMXL4pA_zDkiXeNbI6FavLN9-2_6QA5fqPZjuAicbTUPJOz7dh3W4clREC3JrImsB3I/s320/estimated-death-annual.JPG" width="320" /></a> </div>
<br />Table: 1-1</div>
<br /><br /></div>Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0tag:blogger.com,1999:blog-9140290118247641778.post-75839810063327096832012-04-22T12:25:00.000-07:002012-04-22T12:25:14.652-07:00Patient Adherence<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-size: x-large;"><b>Patient Adherence :</b></span><br /><br />
For many illnesses, treatment depends on difficult fundamental behavioral changes, including alterations in diet,taking up exercise, giving up smoking, cutting down drinking, and adhering to medication regimens that are often complex. Adherence is a problem in every practice; up to 50% of patients fail to achieve full adherence, and one-third never take their medicines.Many patients with medical problems, even those with access to care prematurely. Adherence rates for short-term therapies and are inversely correlated with the number of interventions, their complexity and cost, and the patient's perception of overmedication.<br />
As and example, in HIV-infected patients,adherence to antiretrovira therapy is a crucial determinant of treatmet success. Studies have unequivocally demonstrated a close relationship between patient adherence and plasma HIV RNA levels,SD4 cell counts, and morality.Adherence levels of >95% are needed to maintain virologic suppression. However, studies show that over 60% of patients are <90% adherent and that adherence tends to decrease over time.<br /><br />
Patient reasons for nonadherence include simple forgetfulness being away from home, being busy and changes in daily routine.Other reasons include psychiatric disorders(depression or substance abuse), uncertainty about the effectiveness of treatment,lack of knowledge about the consequences of poor adherence, regimen complexity and treatment side effects.<br />
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Patients seem better able to take prescribed medications than to comply with recommendations to change their diet, exercise habits or alcohol intake or to perform various self-care activities(such as monitoring blood glucose levels at home). The effectiveness of interventions to improve medication adherence has been reviewed by Haynes and colleagues. For short-term regimens, adherence to medications can be improved by giving clear instructions. Writing out advice to patients, including changes in medication, may be helpful. Because low functional health literacy is common(almost half of English-speaking US patients are unable to read and understand standard health education materials), other forms of communication--such as illustrated simple text, videotapes or oral instructions----may be more effective. For non English-speaking patients, clinicians and health care delivery systems can work to provide culturally and linguistically appropriate health services.<br />
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To help improve adherence to long-term regimens, clinicians can work with patients to reach agreement on the goals for therapy, provide information about the regimens, ensure understanding by using the "teach-back"method, counsel about the importance of adherence and how to organize medication-taking, reinforce self-monitoring, provide more convenient care, prescribe a simple dosage regimen for all medications(preferably one or two doses daily), suggest ways to help in remembering to take doses(time of day, mealtime, alarms) and to keep appointments, and provide ways to simplify dosing(medication boxes). Single-unit doses supplied in foil-backed wrappers can increase adherence but should be avoided for patients who have difficulty opening them. Medication boxes with compartments(eg,Medisets) that are filled weekly are useful. Microelectronic devices can provide feedback to show patients wherther they have taken doses as scheduled or to notify patients whether they have taken doses as scheduled or to notify patients within a day if doses are skipped.Reminders are another effective means of encouraging adherence. The clinician acn also enlist social support from family and friends, recruit and adherence monitor, provide a more convenient care environment and provide rewards and recognition for the patient's efforts to follow the regimen.<br /><br />
Adherence is also improved when a trusting doctor-patient relationship has been established and when patients actively participate in their care.Clinicians can improve patient adherence by inquiring specifically about the behaviors in question.When asked,many patients admit to incomplete adherence with medication regimens,with advice about giving up cigarettes,or with engaging only in "safer sex" practices.Although difficult,sufficient time must be made available for communication of health messages.<br />
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Medication adherence can be assessed generally with a single question: "In the past month,how often did you take your medication as the doctor prescribed?" Other ways of assessing medication adherence include pill counts and refill records; monitoring serkum, urine, or saliva levels of drugs or metabolites; watching for appointment nonattendance and treatment nonresponse; and assessing predictable drug effects such as weight changes with diuretics or bradycardia from - blockers. In some conditions, even partial adherence,as with drug treatment of hypertension and diabetes mellitus, improves outcomes compared with nonadherence; in other cases, such a HIV antiretroviral therapy or treatment of tuberculosis, partial adherence may be worse than complete nonadherence.<br />
</div>Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0tag:blogger.com,1999:blog-9140290118247641778.post-56236698220456080722012-04-22T12:20:00.000-07:002012-04-22T12:20:13.656-07:00Approach To Patient<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-size: x-large;"><b>General Approach To Patient:</b></span><br /><br />The medical interview serves several functions.It is used to collect information to assist in diagnosis(the "history" if the present illness),to assess and communicate prognosis,to establish a therapeutic relationship, and to reach agreement with the patient about futher diagnostic procedures and therapeutic options.It also serves as an opportunity to influence patient behavior,such as in motivational adherence.Interviewing techniques that avoid domination by the clinician increase patient involvement in care and patient satisfaction. Effective clinician-patient communication and increased patient involvement can improve health outcomes.</div>Maakalihttp://www.blogger.com/profile/16403652162583160168noreply@blogger.com0