The rest are not indications. The target BP is < 130/85 mmHg.

The rest are not indications.

The rest are not indications.

The rest are not indications.

The rest are not indications.

A 60-year-old diabetic patient is consulting for the first time regarding the treatment of his disease. Which of the following goals would you recommend to him first?

Maintain blood pressure below 110/70 mmHg.

Maintain a body mass index (BMI) less than 21.

Diabetes

Glycated hemoglobin is better than fasting glucose for determining risks of cardiovascular disease and death from any cause. Prevention There is no known preventive measure for type 1 diabetes. Type 2 diabetes—which accounts for 85–90% of all cases worldwide—can often be prevented or delayed by maintaining a normal body weight, engaging in physical activity, and eating a healthy diet. Higher levels of physical activity (more than 90 minutes per day) reduce the risk of diabetes by 28%. Dietary changes known to be effective in helping to prevent diabetes include maintaining a diet rich in whole grains and fiber, and choosing good fats, such as the polyunsaturated fats found in nuts, vegetable oils, and fish. Limiting sugary beverages and eating less red meat and other sources of saturated fat can also help prevent diabetes. Tobacco smoking is also associated with an increased risk of diabetes and its complications, so smoking cessation can be an important preventive measure as well.

[Diet therapy in non-insulin dependent diabetes mellitus (NIDDM)].

The main approach in NIDDM therapy is diet. Most patients present insulin resistance characterized by overweight, VLDL increase, minimal increase of LDL, decrease of HDL cholesterol, and hypertension. The overall goals of nutrition therapy are the maintenance of near normal glucose levels, and the achievement of optimal serum lipid levels with adequate calories for maintaining or attaining a reasonable body weight. In presence of obesity and hypertension even a slightly weight loss could achieve an improvement in metabolic control and in hypertension with a better life expectance. General-ly carbohydrate intake would represent the 50-60% of total caloric amount (with preference to those with low glycemic index), and lipids no more than 35% (less than 10% of these 10-15% from monounsaturated fats with less than 300 mg/day of cholesterol). If elevated very low density lipoproteins level is the primary problem, a beneficial approach is 10% of total caloric intake from saturated fats, 10% from polyunsaturated, and 15-20% from monounsaturated fats with less than 200 mg/day of cholesterol and 40% of carbohydrates. A large amount of fructose (20% of calories) may increase LDL levels but sweeteners as saccarine or aspartame are approved and determine a better diet compliance. Daily consumpion of 20-35 g of dietary fibres from food sources is recommended for metabolic control. Protein intake would be of about 10% of total caloric amount especially in presence of diabetic nepropathy. Alcohol would not exceed 30 g/day for men and 20 g/day for women keeping in mild that alcohol may worsen metabolic control, diet compliance, and may be dangerous itself. For people with hypertension a decrease of dietary sodium intake is recommended. Nutritional recommendations are developed to meet treatment goals and desired outcomes. Monitoring metabolic parameters, blood pressure, and body weight is very important to ensure successful outcomes.

Prediabetes

Management There is evidence that prediabetes is a curable disease state. Although some drugs can delay the onset of diabetes, lifestyle modifications play a greater role in the prevention of diabetes. Intensive weight loss and lifestyle intervention, if sustained, may improve glucose tolerance substantially and prevent progression from IGT to type 2 diabetes. The Diabetes Prevention Program (DPP) study found a 16% reduction in diabetes risk for every kilogram of weight loss. Reducing weight by 7% through a low-fat diet and performing 150 minutes of exercise a week is the goal. The ADA guidelines recommend modest weight loss (5–10% body weight), moderate-intensity exercise (30 minutes daily), and smoking cessation. There are many dietary approaches that can reduce the risk of progression to diabetes. Most involve the reduction of added sugars and fats but there remains a lack of conclusive evidence proving the best approach.

InternalMed_Harrison

Based on the guidelines provided by the ADA, priorities in the treatment of dyslipidemia are as follows: (1) lower the LDL cholesterol, (2) raise the HDL cholesterol, and (3) decrease the triglycerides. A treatment strategy depends on the pattern of lipoprotein abnormalities. Initial therapy for all forms of dyslipidemia should include dietary changes, as well as the same lifestyle modifications recommended in the nondiabetic population (smoking cessation, blood pressure control, weight loss, increased physical activity). The dietary recommendations for individuals with DM include increased monounsaturated fat and carbohydrates and reduced saturated fats and cholesterol (Chap. 421). According to guidelines of the ADA, the target lipid values in diabetic individuals (age >40 years) without CVD should be as follows: LDL <2.6 mmol/L (100 mg/dL); HDL >1 mmol/L (40 mg/ dL) in men and >13 mmol/L (50 mg/dL) in women; and triglycerides <1.7 mmol/L (150 mg/dL). In patients >40 years, the ADA

[Guidelines on treatment of hypertension in the elderly, 1995--a tentative plan for comprehensive research projects on aging and health-- Members of the Research Group for "Guidelines on Treatment of Hypertension in the Elderly", Comprehensive Research Projects on Aging and Health, the Ministry of Health and Welfare of Japan].

We propose the following guidelines for treatment of hypertension in the elderly. 1. Indications for Treatment. 1) Age: Lifestyle modification is recommended for patients aged 85 years and older. Antihypertensive therapy should be limited to patients in whom the merit of the treatment is obvious. 2) Blood pressure: Systolic BP > 160 mmHg, diastolic BP > 90 approximately 10 mmHg. Systolic BP < age + 100 mmHg for those aged 70 years and older. Patients with mild hypertension (140-160/ 90-95 mmHg) associated with cardiovascular disease should be considered for antihypertensive drug therapy. 2. Goal of Therapy for BP: The goal BP in elderly patients is higher than that in younger patients (BP reduction of 10-20 mmHg for systolic BP and 5-10 mmHg for diastolic BP). In general, 140-160/< 90 mmHg is recommended as the goal. However, lowering the BP below 150/85 should be done with caution. 3. Rate of Lowering BP: Start with half the usual dose, observe at the same dose for at least four weeks, and reach the target BP over two months. Increasing the dose of antihypertensive drugs should be done very slowly. 4. Lifestyle Modification: 1) Dietary modification: (1) Reduction of sodium intake is highly effective in elderly patients due to their high salt-sensitivity. NaCl intake of less than 10 g/day is recommended. Serum Na+ should be occasionally measured. (2) Potassium supplementation is recommended, but with caution in patients with renal insufficiency. (3) Sufficient intake of calcium and magnesium is recommended. (4) Reduce saturated fatty acids. Intake of fish is recommended. (2) Regular physical activity: Recommended exercise for patients aged 60 years and older: peak heart rate 110/minute, for 30-40 minutes a day, 3-5 days a week. (3) Weight reduction. (4) Moderation of alcohol intake, smoking cessation. 5. Pharmacologic Treatment: 1) Initial drug therapy. First choice: Long-acting (once or twice a day) Ca antagonists or ACE inhibitors. Second choice: Thiazide diuretics (combined with potassium-sparing diuretic). 2) Combination therapy. (1) For patients without complications, either of the following is recommended. i) Ca antagoinst + ACE inhibitor, ii) ACE inhibitor + Ca antagonist (or low-dose diuretics), iii) diuretic + Ca antagonist (or ACE inhibitor), iv) beta-blockers, alpha 1-blockers, alpha + beta blockers can be used according to the patho-physiological state of the patient. (2) For patients with complications. Drug(s) should be selected according to each complication. 3) Relatively contraindicated drugs. beta-Blockers and alpha 1-blockers are relatively contraindicated in elderly patients with hypertension in Japan. Centrally acting agents such as reserpine, methyldopa and clonidine are also relatively contraindicated beta-Blockers are contraindicated in patients with congestive heart failure, arteriosclerosis obliterans, chronic obstructive pulmonary disease, diabetes mellitus (or glucose intolerance), or bradycardia. These conditions are often present in elderly subjects. Elderly subjects are susceptible to alpha 1-blocker-induced orthostatic hypotension, since their baroreceptor reflex is diminished. Orthostatic hypotension may cause falls and bone fractures in the elderly.

[Comparison of dietary intake of type I diabetic patients and nutritional recommendations].

The management of type I diabetes mellitus requires a careful balance between nutrient intake, energy expenditure and dose and timing of insulin. According to the recommendations of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) the calories should be prescribed according to energy needs to achieve and maintain a desirable body weight. Many studies have shown that diets in which carbohydrates provide 50-60% of total energy are associated with improved blood glucose control and lower levels of LDL cholesterol. Whenever acceptable to the patients, natural foods containing unrefined carbohydrate should be substituted for the highly refined carbohydrates that are low in fiber. The high risk of macrovascular disease in patients with diabetes dictates a need to restrict total fat (25-30% of total energy) and cholesterol intake (300 mg/day). ADA and EASD suggest that reduction of protein intake (0.8 g/kg/day) may reduce proteinuria and progression to renal failure during the earliest stages of diabetic nephropathy. The goal of this study was to describe macronutrient intakes in type I diabetic patients of our Centre by a validated 3 day record. Mean energy intake was 2022+/-427 Kcal/die (vs 2596+/-501 recommended intake). Average protein intake was well above the level of 0.8 g/kg/day required to ensure an adequate protein intake in type I diabetes mellitus. Total fats contributed 29.8+/-7.4 of total energy (vs 27% recommended intake) and saturated fat provided significantly more than 10% of energy. Carbohydrates intake was above 50% of total energy but fiber intakes was substantially lower than the recommendation (12.7+/-5.5 vs 20.1+/-6.6 g/day). These data indicate current problems in the nutritional intake of type I diabetes mellitus; in fact the majority of our group of patients are not meeting the recommended dietary intakes for protein, total fat, saturated fat and fiber.

[Type 2 diabetes in the middle aged. Strict goals from the very beginning!].

Type 2 diabetes mellitus in the middle-aged, that is the onset of diabetes before the age of 65, accounts for fifty percent of all diabetic patients. Because of their relatively long life expectancy, this age group carries a particular risk of experiencing microvascular and macrovascular sequelae. In view of this, the following therapeutic objectives must be strictly applied: near-normalization of blood glucose, HbA1c (< 7.0%), blood pressure (< 140/90 mmHg), LDL cholesterol (< 130/100 mg/dl). Permanent weight reduction in the initial phase may delay disease progression for years. Guidelines issued by the German Diabetes Association require that middle-aged type 2 diabetics should receive 20-24 hours of structured instruction in closed groups, since the brief information provided by the doctor's assistant is inadequate in this age group.

NIDDM: new once-daily intervention for type 2 diabetes mellitus: Diaprel MR.

Pharmacological treatment of hyperglycemia should address to both abnormalities in T2DM treatment, that is reduction of insulin resistance and restoration of normal insulin secretion. Gliclazide is a sulfonylurea compound oral hypoglycemic drug that has a unique feature of restoring the first-phase insulin secretion, which is lost in T2DM being one of the early features of disease. Laboratoires Servier conducted in Romania a an open non randomized surveillance on the efficacy and safety of Diaprel MR in type 2 diabetic patients. 199 patients in 14 treatment centers were enrolled. Eligibility criteria were as it follows: men and women with diabetes, previously on diet alone and not treated with other OAD, over 35 years old with FPG (mg/dl) at enrollment between 126 and 180. The clinical trial lasted for 16 weeks. During this period the doctors examined the patients 6 times. First visits were at a 2 weeks interval and the last two visits at a 4 weeks interval. At each visit the doctor renewed the prescription for the subsequent period according to the following protocol: the starting dose was 30 mg Diaprel MR/day, if the FPG (mg/dl) was over 140 (at the next visit) the dosage was increased with 30 mg Diaprel MR/day, if the FPG (mg/dl) was under 140 the dosage remained the same as the previous dosage. The maximum dosage was 120 mg Diaprel MR/day. The following parameters were measured on first and last (seventh) visit: blood pressure (systolic and diastolic), heart rate (bpm), body mass index-BMI (kg/m2), fasting plasma glucose FPG (mg/dl and mmol/l), glycated hemoglobin HbA1c (%) and Hb-Hct (mg/dl-%), creatinine (mg/dl), SGPT (UI/I), cholesterol (mg/dl) and triglycerides (mg/dl). Blood pressure (systolic and diastolic), heart rate, BMI and FPG were measured from the second to sixth visit also. On each visit there was registered other data such as: associated illnesses, concomitant medication and adverse events. Primary end points. The average values of end points HbA1c (%) and PFG (mg/dl) registered a significant decrease during the 16 weeks of medication, from the enrollment moment (S0) to the last week (S16). The decrease was significant on the total sample of the main analysis group but also on subsamples of age, gender and BMI. HbA1c (%) average values decreased in the main analysis group (S16 compared to S0): with 22% on the total sample (from 7.7 to 6.0); p < 0.05. FPG (mg/dl) average values decreased in the main analysis group (S16 compared to S0): with 21% on the total sample (from 159 to 126); p < 0.05. Secondary end points. There were no significant changes registered in the average level of cholesterol and triglycerides, BMI, diastolic blood pressure, heart rate, creatinine, SGPT. A significant decline of the average systolic blood pressure was registered. Diaprel MR can be used safely in diabetic patients newly diagnosed, uncontrolled on diet or other oral antidiabetic drugs, overweight, safely in those with cardio-vascular disease, or in patients with creatinine clearance 50-80 ml/min.

Prevention of coronary heart disease. Part I. Primary prevention.

The first concern in primary prevention is the physician's belief that primary prevention is important for all adults and that intervention can significantly affect risk. Given the coronary plaque burden over many years and the importance of the development of healthy lifestyles early in adulthood to decrease coronary plaque burden, there are excellent reasons to begin prevention even with young adults. At the very least, a patient seen for any reason should provide a smoking history, have knowledge of the presence of early CHD in first-degree relatives and measurements of blood pressure, height, and weight, provide evidence for a cholesterol level within 5 years (after age 20 according to NCEP guidelines or in middle age according to ACP guidelines), and be given an assessment of glucose tolerance or diabetes. Information about alcohol intake and physical activity status are also of some importance. Other than height, weight, and blood pressure, during the physical examination, the physician should initially assess the strength of pulses in the lower extremities, evidence for carotid or femoral bruits, and eyegrounds for retinal arterial changes, and the skin and subcutaneous tissue should be examined for xanthomas and the eyes should be examined for corneal arcus and xanthelesma. These elements should be part of any initial examination by a primary care physician and are not extraordinary. In addition to lipid and blood sugar analyses, other evaluations may include blood urea nitrogen and creatinine and electrolytes in patients with hypertension or diabetes or in patients who are on antihypertensive agents. It may be prudent to obtain an ECG for patients who are older than 40 years. The elements mentioned above are the elements of the history, physical examination, and laboratory examination in subjects without a past history of CHD and with no clinical evidence for CHD. Primary prevention management begins with a discussion of risk factors with the patient. The key interventions aim at the lowering of blood pressure to at least less than 140/90 mm Hg, the complete cessation of smoking, the lowering of lipid levels to less than 130 mg/dL, the lowering of triglycerides to less than 200 mg/dL (or, some would argue, < 150 mg/dL), and the attempt to keep HDL cholesterol above 35 mg/dL (more than 40 to 45 mg/dL is a better goal) with the use of lifestyle modification. For patients with diabetes, strict control of glucose levels is essential to minimize disease of the microvasculature and possibly to minimize progressive renal disease. There are several lifestyle modifications for lipids. For patients with elevated LDL cholesterol, modifications include a less than 30% fat calorie diet and less than 300 mg of cholesterol intake daily, with fat calories approximately equally distributed among saturated fats, polyunsaturated fats, and monounsaturated fats (1/3, 1/3, 1/3; rule of 3s). The assistance of a dietician is extremely helpful in this regard. For patients with a low HDL cholesterol, weight reduction (for overweight patients) by calorie control and increased physical activity and smoking cessation will have some modest effect. For patients with elevated triglycerides, a diet similar to that for lowering of LDL cholesterol with the addition of stricter calorie limitation, avoidance of refined sugars, increase in complex carbohydrates, and avoidance of alcohol will be helpful. A decrease in the percent of fat calories to 20% to 25% will be of assistance to those patients with particularly high triglycerides. The treatment of underlying conditions such as diabetes mellitus, hypothyroidism, liver disease, and some renal conditions may also significantly modify high triglycerides. For patients with hypertension, limitation of sodium to 2 gm/d (6 gm sodium chloride), limitation of alcohol to 1 to 2 drinks a day, increased physical activity, and weight reduction are the key lifestyle modifications. (ABSTRACT TRUNCATED)

The dietary treatment of diabetes mellitus.

The most important dietary goal for individuals with type I diabetes mellitus is the establishment of a regular meal pattern with consistent day-to-day caloric and carbohydrate intake. Ideally, the diet should contain 55 to 60 per cent of total calories as carbohydrate, less than 30 per cent of calories as fat, less than 10 per cent of calories as saturated fat, and less than 300 mg of cholesterol per day. The best tool for helping type I individuals achieve these objectives is the Exchange Lists for Meal Planning. A second important dietary goal in type I diabetes is to avoid weight gain during intensive treatment programs. The most important dietary and therapeutic goal in obese persons with type II diabetes is weight loss. Unfortunately, no dietary method, whether initiated by self-help groups like TOPS, physicians, or other health care professionals, has been demonstrated to be effective in achieving and maintaining weight loss. Nevertheless, some individual patients will be successful, and it therefore is appropriate to attempt weight reduction with a balanced diet moderately restricted in calories. A reduction of 500 calories per day below the weight maintenance level is reasonable and can be expected to produce weight loss of about 1 lb per week. For those type II diabetic patients who are not able to lose weight and are at least twice their ideal body weight, gastric reduction surgery could be considered. The Glycemic Index of Foods is a new concept that has not been evaluated adequately. Recent evidence suggests that differences among foods are reduced when the foods are combined in a meal and thus raises questions about the utility of glycemic indexing. The longstanding restriction on the use of sucrose in the diabetic diet is without scientific basis. Recognizing this, the American Diabetes Association recently sanctioned consumption of modest amounts of sucrose in the diabetic diet. Although conclusive evidence is not yet available that high fiber diets improve glycemic control or reduce serum lipids in diabetic persons, it appears reasonable to encourage the consumption of natural foods high in soluble fiber. Vegetables (particularly legumes), oats, and many fruits are good sources. The American Diabetes Association recommends a goal of 40 g of soluble fiber intake per day. The dietary treatment of diabetes is likely to be more successful if physicians learn more about its essential features and pay it greater attention. The goals of dietary therapy are difficult to achieve and often require significant sacrifices.(ABSTRACT TRUNCATED AT 400 WORDS)

Clinical and Anthropometric Improvements with a Tailored Dietary Approach in Pediatric Crohn's Disease.

Pediatric Crohn's disease (CD) is more common today than in prior decades. Therapeutic goals in children with CD are to reduce symptomatology, promote normal growth, and avoid nutritional deficiencies. Diet plays a crucial role in the treatment of CD. However, there is a lack of comprehensive guidelines and individualized dietary approaches. A 12-and-a-half-year-old boy presented with chronic diarrhea, intermittent fever, abdominal pain, and a history of eczema. At the first visit, his body mass index (BMI) was 14.4, and his BMI-for-age was in the 1st percentile, classifying him as underweight. He received the diagnosis of Crohn's ileocolitis and gastritis and was unresponsive to treatment for 10.5 months. The patient was placed on a tailored dietary approach based on the in vitro leukocyte activation assay-MRT (LAA-MRT®), known as the Lifestyle Eating and Performance (LEAP) program. The LEAP program is an elimination diet built on the selection of less-immune-reactive foods and chemicals identified by the LAA-MRT® results. After 39 days of following the LEAP program, his fecal calprotectin levels decreased from >2000 μg/g to 185.9 μg/g. A repeat esophagogastroduodenoscopy (EGD) and colonoscopy with 10 biopsies showed complete histologic remission 1 year after beginning diet therapy. At that point, the patient discontinued his pharmacologic therapy and maintained clinical remission of CD after more than 3 years of follow-up. In addition, his anthropometric measurements and laboratory biomarkers were normalized. This case presents evidence supporting the use of the LEAP program in clinical practice as an adjunctive, tailored dietary option to manage pediatric CD.

[Six-year follow up on recently diagnosed NIDDM patients].

The six-year prospective data on 100 newly detected NIDDM patients aged 40-69 years were analysed. After careful and controlled dietetic training, the carbohydrate metabolism parameters (glycohaemoglobin, mean blood sugar level and glycosuria), the physical status, fundus picture and laboratory data (lipids and renal function) were examined yearly and the alterations of the treatment were registered. 24 patients dropped out during six years. 10 patients died. The carbohydrate status was also favourable and a moderate weight reduction was reached. After two years 59% of the patients proved well controlled. At the end of six years 41% of the patients were still well controlled merely by dietary means. The data were compared with those on 100 similarly detected new NIDDM patients whose education and control were provided by family physicians. There were non essential differences between the two groups in specific complications, BMI and lipids. The level of carbohydrate metabolism control was significantly better in the diabetic clinic-controlled patients; the proportion of sulfanylurea-treated patients was only 40.5% after six years compared with 73% among family physicians-controlled patients. The importance of a correct and controlled diet, good education and continuous control is emphasized.

Management of hypertension

Hypertension is managed using lifestyle modification and antihypertensive medications. Hypertension is usually treated to achieve a blood pressure of below 140/90 mmHg to 160/100 mmHg. According to one 2003 review, reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34% and of ischaemic heart disease by 21% and reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease. Blood pressure target For most people, recommendations are to reduce blood pressure to less than or equal to somewhere between 140/90 mmHg and 160/100 mmHg. In general, for people with elevated blood pressure, attempting to achieve lower levels of blood pressure than the recommended 140/90 mmHg will create more harm than benefits, in particular for older people. In those with diabetes or kidney disease, some recommend levels below 120/80 mmHg; however, evidence does not support these lower levels.

Reduction in body weight helps to delay the onset of diabetes even in non-obese with strong family history of the disease.

Of the 1200 non-diabetic offspring of non-insulin-dependent diabetic patients registered under the prevention programme, 262 (M:F 189:73) were available for analysis with greater than or equal to 4 years of follow-up. All of them had been prescribed a calorie restricted diet to suit their body weight, occupation and age, and were advised to restrict the use of refined carbohydrates and fats. Regular exercise was also advised. Compliance with these prescriptions was assessed at each follow up. At the time of analysis, it was noted that only 14.5% had developed diabetes in a period of 8 +/- 4.2 years even though many of them had impaired glucose tolerance at entry in the programme. Multiple regression analysis showed that initial 2 h plasma glucose, initial glucose tolerance and gain in body weight were strong predictors of diabetes. Weight loss occurred in persons who adhered to diet and exercise programmes and conversion to diabetes was lower in them compared to those who gained weight (P < 0.002). Although the rate and degree of obesity is less among Indians, it has been observed in several earlier studies that even a minor increase in body mass index increased the risk of diabetes. This study highlights the fact that measures to control weight helps to delay the onset of diabetes even in the non-obese despite a strong family history of the disorder.

Anterior cerebral artery syndrome

Management Pulse oximetry can guide the use of supplemental oxygen to maintain oxygen saturation greater than 94%. Hyperoxia should be avoided as may be detrimental in stroke. Hypertension is common in an acute ischemic stroke. A low BP is uncommon and may indicate symptoms exacerbation of a previous stroke due to poor perfusion. Blood pressure of 220/120 mmHg should receive treatment. There is a consensus approach of allowing permissive hypertension up to 220/120 mmHg for patients that are not candidates for thrombolysis.[21] However, for a patient that is a potential candidate for alteplase, attempt to control BP should be made immediately as goal BP for initiation of IV alteplase is 185/110 mmHg. Usually, titratable short-acting intravenous hypotensive agents are recommended to avoid dropping the BP too much once the patient is at goal. Hypotensive agents that can be options include labetalol, nicardipine, clevidipine, hydralazine, enalaprilat.[21]

[Long-term results (5-year minimum) of the diet treatment of adult obesity. Elements of weight prognosis. Apropos of 138 patients].

One hundred and thirty-eight out of 250 obese patients admitted to hospitals between 1972 and 1976 for dietetic treatment comprising 1,000 calories and 100 g carbohydrates were recontacted with a minimum follow-up of 5 years. Seventy-five patients refused to answer the questionnaire or attend an outpatient appointment. Four patients were later excluded from the study. Finally, fifty-nine patients were reassessed. The percentage of good results at 5 years (defined as greater than or equal to 5 p. 100 loss of initial body weight) was 45.5 p. 100 of those reassessed, a minimum of 20 p. 100 of the total number recontacted. The course of obesity was not linear. During the follow-up period there were 45.5 p. 100 of secondary failures (regain of initial body weight after having lost at least 5 p. 100), but also 17 p. 100 of secondary successes. The prognosis was not related to the age of onset of obesity, its duration, sex, occupation, alleged trigger factors, apparent motivation, duration of hospital admission, or treatment before or after hospitalisation. The prognosis was better in patients under 30 or over 50 years of age at the time of treatment (P less than 0.01) and when the body weight had not varied +/- 5 kg in the years preceding treatment (P less than 0.01). The following factors may also play a favourable role (but not statistically significant): the degree of obesity (better results in major obesity greater than or equal to 50 p. 100 overweight), a positive family history, the detection of a physical factor (glucose intolerance) during investigation, and the repetition of medical check-ups after initial counselling.

The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 - therapy.

To update the evidence-based recommendations for the prevention and treatment of hypertension in adults for 2010. For lifestyle and pharmacological interventions, randomized trials and systematic reviews of trials were preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the general lack of long-term morbidity and mortality data in this field. Progressive renal impairment was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease. A Cochrane Collaboration librarian conducted an independent MEDLINE search from 2008 to August 2009 to update the 2009 recommendations. To identify additional studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence. For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to 1500 mg (65 mmol) per day in adults 50 years of age or younger, to 1300 mg (57 mmol) per day in adults 51 to 70 years of age, and to 1200 mg (52 mmol) per day in adults older than 70 years of age; perform 30 min to 60 min of moderate aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week for men or nine standard drinks per week for women; follow a diet that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources, and that is low in saturated fat and cholesterol; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in patients with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, considerations for initial therapy should include thiazide diuretics, angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. The combination of ACE inhibitors and ARBs should not be used, unless compelling indications are present to suggest consideration of dual therapy. Agents appropriate for first-line therapy for isolated systolic hypertension include thiazide diuretics, long-acting dihydropyridine CCBs or ARBs. In patients with coronary artery disease, ACE inhibitors, ARBs or betablockers are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. In selected high-risk patients in whom combination therapy is being considered, an ACE inhibitor plus a long-acting dihydropyridine CCB is preferable to an ACE inhibitor plus a thiazide diuretic. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian lipid treatment guidelines. Selected patients with hypertension who do not achieve thresholds for statin therapy, but who are otherwise at high risk for cardiovascular events, should nonetheless receive statin therapy. Once blood pressure is controlled, low-dose acetylsalicylic acid therapy should be considered. All recommendations were graded according to the strength of the evidence and voted on by the 63 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 80% consensus. These guidelines will continue to be updated annually. The Canadian Hypertension Education Program process is sponsored by the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the College of Family Physicians of Canada, the Canadian Pharmacists Association, the Canadian Council of Cardiovascular Nurses, and the Heart and Stroke Foundation of Canada.

[Liberalized diabetic diet for type I diabetics under intensive insulin injection therapy. Follow-up observations for over 2 years].

The dietary habits and metabolic status of 14 selected ambulant type-1 diabetics, who were previously treated with conventional insulin therapy, were investigated over a period of 2 years under intensified insulin injection therapy. In this, multiple doses of regular insulin in combination with intermediate-acting insulin were injected daily and the regular metabolic controls as well as adjustment of the insulin dosage were undertaken by the patients themselves. Whereas conventional insulin therapy made exclusive use of intermediate-acting insulin, 41% of the daily dose in the intensified insulin injection therapy was regular insulin. The total daily insulin dose of 51 +/- 12 U/d was therefore not significantly different from that in the conventional insulin therapy (49 +/- 10 U/d). During the intensified insulin injection therapy the usual diabetic diet was relaxed in several aspects: neither the daily intake of fat, protein and calories, nor substitution in the diet using exchange lists was specified. Despite this liberalization HbA1c values decreased significantly from 9.3 +/- 1.2% to 7.8 +/- 0.7% (P less than 0.05) and blood lipids remained in the normal range. The results of this retrospective investigation lead to the conclusion that despite some measure of diet liberalization, selected, trained, type-1 diabetics of normal body weight and without primary dyslipoproteinaemia can attain good metabolic control under intensified insulin injection therapy.

Health status of Asian Americans

With the adaptation of American culture, immigrant populations can be seen to have increased risks of diseases as Western diets are being introduced into their daily food consumptions. However, there is a heightened risk of type 2 diabetes amongst Asian Americans as its presence makes up 21% of the Asian American population, twice as high as non-Hispanic whites. Due to various genetic and environmental factors, Asian Americans are more likely to develop type 2 diabetes than other racial and ethnic groups, even though their body mass index (BMI) tends to be lower. Asian Americans have a higher percentage of body fat for their BMIs which in turn elevates the risk of type 2 diabetes when BMI levels are lowered; they in fact may have a higher percentage of body fat which contributes to a greater risk of developing diabetes and other health concerns that are commonly overseen. Because of their BMIs, which are usually lower than other racial and ethnic groups, there is a common

Dietary therapy in NIDDM.

Clearly the dietary treatment of the NIDDM patient remains an act of faith bearing in mind the poor compliance of the patient to dietary advice, and the lack of long-term studies confirming the efficacy of diets (old or new) in the prevention of diabetic vascular complications. Few of the newer recommended diets seem to have been tested in the hurly-burly of the busy, understaffed diabetic clinic. Perhaps another major hurdle has been the attitude of patients and doctors in failing to regard diet therapy as a form of treatment, akin to tablets. The phrase 'I eat my diet, doctor, then I have my usual meal' sums up the problem. There needs to be a change in attitude to diet by both doctors and patients so that the dietary changes suggested should be eating habits which would become second nature to patients--the so called 'healthy eating'--more fibre, less refined carbohydrate, less total and saturated fat and more polyunsaturated fats. It seems difficult for a majority of NIDDM patients to add onto 'healthy eating' calorie restriction to achieve weight loss. This difficulty also applies to non-diabetic obese subjects with similar poor results. One cannot help but feel that NIDDM patients should benefit from the general change in attitude of the general population towards nutrition, but reinforced education concerning diet goals for NIDDM patients is an urgent requirement and needs closer examination by the diabetic health care team as to how it may be delivered to the individual NIDDM patients. Perhaps dietitians in particular should become more critical in their approach to diet strategies and should investigate and report on the results of this treatment.

Outcomes in weight loss, fasting blood glucose and glycosylated hemoglobin in a sample of 415 obese patients, included in the database of the European accreditation council for excellence centers for bariatric surgery with laparoscopic one anastomosis gastric bypass.

Obesity is a risk factor for the development of diseases such as type 2 Diabetes Mellitus. Bariatric surgery with laparoscopic single anastomosis gastric bypass is an effective treatment for morbid obesity and diabetes type 2 complete remission, and it has been proven to generate an improvement in glycemic levels and glycosylated hemoglobin (HbA1c) keeping the weight loss for a long time. In a period of time between June 2002 until May 2012, 2070 patients underwent surgery with LOAGB technique. Between January 2010 an May 2012, 415 patients were included in the European Accreditation Council for Excellence Centers for Bariatric Surgery (EAC-BS) database, from which 79 patients with a glycemic level disturbance in the preoperative blood sample where chosen. Of this group, 47 patients were pre-diabetic (fast plasma glucose ≥ 110 mg/dl ≤ 125 mg/dl) and glycosylated hemoglobin (HbA1c) levels between 5.7-6.4% and 32 were diabetic (fast plasma glucose ≥ 126 mg/dl) and glycosylated hemoglobin (HbA1c) levels ≥ 6.5%. We described the weight evolution, the excess body mass index lost percentage (%EBMIL) the glycemia and the glycosylated hemoglobin levels; and we reported regular laboratory controls during the first year after surgical intervention. Both patient groups achieved their lowest mean weight loss 12 months after surgery, being average weight in the pre-diabetic group 62,41 ± 10,93 and 68,36 ± 11,16 in the diabetic group. Since 3 months after surgery, pre-diabetic patients achieve a mean BMI < 30, according to the Spanish Society for Obesity Study (SEEDO 2007) this amount is outside of the definition of obesity. Not being the case of the diabetic patients who don´t achieve this result until 6 months after surgery. The weight loss was excellent in both study groups, achieving an excess body mass index loss percentage (% EBMIL) greater than 65%, since the first three-month postoperative control. Glycemia levels descend in both groups, achieving the pre-diabetic group a mean glycemia level of < 110 mg/ dl in the second day after LOAGB surgery. Pre-diabetic patients maintain more stable glycemia with better controls, and very favorable outcomes 12 months after surgery. The diabetic patients achieve the mean glycemia level of < 110 mg/dl at the first month after surgery and maintained it 12 months after surgery which is the time of this study. The glycosylated hemoglobin levels descended in both groups, achieving levels of 4% three months after surgery in the prediabetic group and 4.8% at six months in the diabetic group. LOAGB proved to be an efficient bariatric technique for complete remission of pre-diabetes and diabetes mellitus type 2 and also with the excess weight loss resolution. We showed that the excess weight loss, the glycemia and glycosylated hemoglobin levels continue being normal after one year of follow up after surgery. The best results are obtained in pre-diabetic patients who underwent LOAGB, this group is integrated with people who are at high risk of suffering a deterioration of their obesity and a rapid advance of the diabetes and the associated comorbidities, that's why surgery has to be performed as soon as possible when the medical exam continues being favorable.

[Identification of factors predicting early evolution of secondary oral hypoglycaemic agent failure and evaluation of clinical standards applied by primary care physicians during qualification to insulin therapy of patients with type 2 diabetes].

Effective control of metabolic disturbances, in particular hyperglycaemia, hypertension and lipid abnormalities, is a prerequisite condition for clinically important reduction in the risk of death related to diabetes and its complications. It appears that type 2 diabetes is a progressive disease and hyperglycaemia aggravates with time. Secondary failure of oral hypoglycaemic agents is a common evolution of long-standing type 2 diabetes and placement on insulin is necessary when maximal sulfonylurea therapy is inadequate. This study was designed to identify factors predicting early hyperglycaemia progression and evolution of secondary oral hypoglycaemic agent (OHA) failure, estimate the prevalence of metabolic disturbances associated with type 2 diabetes and evaluate clinical practices of family physicians during qualification to insulin therapy. Medical records of 56 diabetic patients, 24 males and 32 females with a mean age of 65 years (42-91 yrs), were analyzed. Information about fasting plasma glucose and lipid levels, blood pressure, body mass, kidney status, coronary artery disease and other complications, and treatment were retrospectively extracted from patient charts. All patients were treated by their family physicians. The duration of the disease ranged from 1 to 18 years. All patients were started on insulin during the last three years. Metabolic abnormalities, especially hypertension, lipid abnormalities and obesity, were common findings in type 2 diabetes patients. Hypertension occurred in 77% of patients. Treatment of hypertension was generally not effective and only 16% of patients fulfilled recommendations of ADA. Lipid abnormalities were common. EDPG and ADA criteria were met by 30% and 18% of the patients, respectively. BMI lower than 25 kg/m2 was found in 23% of patients. A multiple regression model and analysis of proportional hazard regression according to Cox were used to identify factors independently associated with early progression of hyperglycaemia and early evolution of secondary OHA failure. It was found that high fasting glycaemia in the early phase of OHA treatment and history of hypertension prior to diabetes, in particular high diastolic pressure, were independent predictors of early progression of hyperglycaemia and necessity of adding insulin to the hypoglycaemic regimen. Hypertension prior to diabetes increased by more than twice the relative risk of exceeding 150 and 180 mg% for glycaemia and the risk of switching to insulin. Assessment of compliance with clinical recommendations by family physicians revealed a significant delay in qualification to insulin therapy. Treatment with OHA was continued in spite of clear signs of metabolic decompensation. On the average, OHA were continued for 4.5 years after fasting glycaemia exceeded 150 mg%. Insulin was added to the hypoglycaemic regimen when fasting glycaemia reached an average of 234 mg% and the maximal postprandial glycaemia reached 390 mg%. The present findings suggest that compliance with clinical recommendations in primary care as a measure to retard complications in patients with type 2 diabetes should be improved, especially with regard to control of hyperglycaemia, hypertension and dyslipidemia.

Sweeteners and beta-glucans improve metabolic and anthropometrics variables in well controlled type 2 diabetic patients.

The introduction of fat and carbohydrates replacers has been a revolutionary advance in treating obesity and diabetes mellitus. Since these materials have shown to have beneficial effects on the metabolic profiles of diabetic patients, they should be useful in designing specific foods for patients with diabetes. To compare metabolic and anthropometric improvements elicited by a diet based on the American Diabetic Association's nutrition recommendations with a modified, low-energy diet incorporating fat replacers and non-sucrose sweeteners. A total of 16 male, well controlled type 2 diabetes patients were divided into two groups of eight; one group received the diet based on the American Diabetic Association's nutrition recommendations, and the other was fed a modified, low-calorie diet containing a fat replacer (beta-glucans derived from oats) and the sweeteners, sucralose and fructose. Both groups were maintained on their respective diets for 4 weeks. All patients performed daily aerobic exercise consisting of walking for 60 minutes. Body weight, body mass index, basal glycemia, hemoglobin HbA1C, and lipid profile were determined in each patient before starting the diets and after 4 weeks of dietary intervention. Both diets produced significant improvements in weight, body mass index, lipid profile, basal glucose, and HbA1C. However, the experimental diet was superior to the American Diabetic Association's diet in improving metabolic and anthropometric profile: greater increase in HDL cholesterol and larger decreases in HbA1C, weight, and body mass index. A diet incorporating a fat replacer and non-sucrose sweeteners produced a greater improvement in metabolic and anthropometric variables in well controlled type 2 diabetic patients when compared with a diet based on American Diabetic Association's nutrition recommendations.

Diet liberalization and metabolic control in type I diabetic outpatients treated by continuous subcutaneous insulin infusion.

In 10 type I diabetic outpatients treated by continuous subcutaneous insulin infusion (CSII), dietary habits and metabolic control were investigated. Under conditions of a conventional diabetes diet (including 5-6 meals per day and a strictly planned meal intake) as well as under a "less restricted diabetes diet" (e.g., free choice of number, timing, and amount of carbohydrate intake) near normoglycemia could be achieved. Mean daily blood glucose levels did not change significantly when the patients' nutrition was alternated between both diets. During the "less restricted diabetes diet," the patients opted for a rather high fat intake (51 +/- 5% fat, 34 +/- 5% carbohydrate, and 15 +/- 2% protein). Despite this unintended dietary behavior, serum lipids and body weight remained normal after an observation period of 4-6 mo. It is concluded that during permanent near normoglycemia achieved by CSII a partial liberalization of the diabetes diet does not introduce any short-term or long-term metabolic risk factors for cardiovascular diseases.

Liraglutide

Liraglutide was approved for medical use in the European Union in 2009, and in the United States in 2010. In 2019, it was the 142nd most commonly prescribed medication in the United States, with more than 4million prescriptions. Medical uses Liraglutide is a medication used for the treatment of type 2 diabetes or obesity. Type 2 diabetes Liraglutide improves control of blood glucose. As of 2017 it is unclear if incretin mimetics like liraglutide affect a person's risk of death. In diabetes it is a less preferred agent. It may be used in those in who metformin and another antidiabetic medication such as a sulfonylurea are not sufficient. Obesity Liraglutide may also be used together with diet and exercise for chronic weight management in adult patients. The body mass index (BMI) needs to be greater than 30 kg/m2, or greater than 27 kg/m2 together with high blood pressure, type 2 diabetes mellitus, or dyslipidemia.

[Treatment of diabetes in metabolic syndrome].

Hyperglycaemia is a typical feature of metabolic syndrome (MeTS) and one of its independent diagnostic criteria. The term includes impaired glucose homeostasis (impaired fasting glucose and impaired glucose tolerance) and type 2 diabetes mellitus. Although glycaemic control has been shown to lower the risk of microvascular events, the effect of intensive glycaemic control on macrovascular outcomes is less clear. Epidemiological studies show hyperglycaemia, particularly the postprandial one, to be a clear risk factor for cardiovascular (CV) mortality and morbidity. However, the intervention studies are less conclusive. The large interventional studies published in 2008 and 2009 (UKPDS, VADT, ACCORD, ADVANCE, RECORD) advocate the controlling of nonglycemic risk factors (through blood pressure control, lipid lowering with statin therapy, aspirin therapy, and lifestyle modifications) as the primary strategies for reducing the burden of CV disease in people with diabetes, and demonstrated the need for individualized approach to the patients' care in terms of blood glucose control. The patients with shorter duration of type 2 diabetes and without established atherosclerosis might reap CV benefit from intensive glycemic control. Conversely, it is possible that potential risks of intensive glycaemic control (hypoglycaemia) may outweigh its benefits in other patients, such as those with a very long duration ofdiabetes, known history of severe hypoglycemia, advanced atherosclerosis, and advanced age/frailty. According to the latest recommendations of the Czech Diabetes Society that are in line with the European and US standards the best way to protect type 2 diabetic patients against coronary and cerebrovascular disease is to target all cardiovascular risk factors (blood pressure treatment, including lipid-lowering with statins, aspirin prophylaxis, smoking cessation, and healthy lifestyle behaviors hypertension, dyslipidemia, obesity and other symptoms of metabolic syndrome. The target HbA1c levels in patients with the low CV risk shoul be below 4.5%. Less strict goals (HbA1c below 6%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, or extensive comorbid conditions or those with long-standing diabetes. The individual targets should be achieved safely (without hypoglycaemias). Slow advancing in diabetes compensation is preferred. Lifestyle changes are the cornerstone of therapy. Metformin is the drug of choice; its administration, together with lifestyle changes, should be initiated immediately after the diagnoses of diabetes. If monotherapy does not provide satisfactory glucose control, other oral antidiabetic agents or insulin are added to the combination. Since it is not known which hypoglycaemic agents are beneficial from the perspective of long-term patient prognosis, the selection is liberal. Contraindication of the various farmaceuticals must be respected. It is possible to use a range of different combinations, metformin is administered with a glitazone (zero risk of hypoglycaemias is the advantage) with sulphonylurea derivatives (low price is the advantage) with glinides, with incretins, acarbose, antiobesity agents or insulin. The next step is a triple combination of hypoglycaemic agents with different mechanisms of action. Therapy also includes education focusing on changes to dietary and lifestyle habits, including smoking cessation, and education related to the prevention of complications, with particular regard to prevention of diabetic foot and atherosclerosis.

[Arterial hypertension and dyslipidemia in patients with chronic kidney disease (CKD). Anti-platelet aggregation. Goal oriented treatment].

TREATMENT OF ARTERIAL HYPERTENSION - Blood pressure (BP) should be regularly measured in all patients with CKD (Strength of Recommendation C). - BP control and proteinuria reduction delay progression of CKD (Strength of Recommendation A) and reduce cardiovascular risk (Strength of Recommendation C). Thus, control of both factors should be the treatment objective. - The BP target in patients with CKD should be < 130/80 mmHg, and 125/75 mmHg if proteinuria is > 1 g/24 hours (Strength of Recommendation A). - Lifestyle changes should be made: low-sodium diet (less than 100 mEq/day of sodium or 2.4 g/day of salt); weight reduction if patient is overweight (body mass index 20-25 kg/m2); regular aerobic physical exercise and moderate alcohol intake for BP control and prevention of cardiovascular risk (Strength of Recommendation A). - The choice of the antihypertensive drug in patients with CKD depends on the etiology of CKD, cardiovascular risk, or presence of clinical or subclinical cardiovascular disease (Strength of Recommendation A). - Two or more antihypertensive drugs are usually required to control blood pressure in patients with CKD (Strength of Recommendation B), and will frequently include a diuretic, which in stages 4-5 should be a loop diuretic (Strength of Recommendation B). - Renin-angiotensin-aldosterone system (RAAS) inhibitors are first choice drugs in patients with diabetic nephropathy, patients with non-diabetic nephropathy with a protein/creatinine ratio higher than 200 mg/g, and patients with heart failure (Strength of Recommendation A). The combination of ACEIs and ARBs is indicated for reducing proteinuria that remains high despite treatment with a RAAS inhibitor, provided potassium levels do not exceed 5.5 mEq/L (Strength of Recommendation B). - When RAAS blockers are started or their dose is changed in patients with advanced CKD, kidney function and serum potassium levels should be monitored at least after 1-2 weeks. DIAGNOSIS AND TREATMENT OF DYSLIPIDEMIA - A complete evaluation of the lipid profile including total cholesterol, LDL-C, HDL-C, and triglycerides should be performed in any patient with CKD at baseline and at least annually (Strength of Recommendation B). - In patients with stage 4-5 CKD and LDL-C >or= 100 mg/dL, treatment to decrease levels to < 100 mg/dL should be considered because of their high CV risk. This reduction is recommended in secondary prevention and in primary prevention in diabetic patients. Lipid-lowering treatment is recommended in all other patients, although no evidence showing its benefits is available yet (Strength of Recommendation C). - In patients with stage 4-5 CKD and triglyceride levels >or= 500 mg/dL which are not corrected by treating the underlying cases, treatment with triglyceride-lowering drugs may be considered to reduce the risk of pancreatitis. However, treatment with fibrates should be used with caution, and these drugs should not be associated to statins due to the risk of rhabdomyolysis (Strength of Recommendation C). There is little experience on the efficacy and safety of omega-3 fatty acids for the treatment of hypertriglyceridemia in patients with grade 4-5 CRF, but they may be considered a possibly safer alternative to fibrates (Strength of Recommendation C). SMOKING - Smoking is a cardiovascular risk factor and a risk factor for progression of kidney disease in patients with CRF (Strength of Recommendation B). - Use of active measures to achieve smoking cessation is recommended in patients with CRF (Strength of Recommendation C). HOMOCYSTEINE - Hyperhomocysteinemia has been postulated as a cardiovascular risk factor in the general population and in kidney patients, but the available evidence is not consistent. - There is no evidence that vitamin therapy decreases cardiovascular risk in patients with CRF, and recommendation of routine vitamin measurement and start of vitamin therapy to reduce cardiovascular risk in these patients is therefore questionable (Strength of Recommendation B). LEFT VENTRICULAR HYPERTROPHY - Left ventricular hypertrophy (LVH) is a cardiovascular risk factor in patients with CRF (Strength of Recommendation B). - It is advisable to perform an echocardiogram at baseline and every 12-24 months and to consider treatments allowing for LVH regression (Strength of Recommendation C). The approach to LVH should be early and multifactorial because its reversibility is limited once established (Strength of Recommendation C). - RAAS blockade with ACEIs or ARBs partially reverts LVH in patients with CRF (Strength of Recommendation B). ANTI-PLATELET AGGREGATION - Because of the high cardiovascular risk in patients with CKD, anti-platelet aggregant therapy, especially low-dose aspirin, would be indicated in patients with type 2 diabetes as primary prevention, and in all patients with CKD as secondary prevention. There is however no evidence of the benefits of anti-platelet aggregant therapy in primary prevention in patients with CKD, particularly in stages 4-5; indication for treatment in this situation should therefore be individualised because of its greater risk of bleeding. - Adequate good blood pressure control should previously be achieved to minimise the risk of haemorrhagic stroke (Strength of Recommendation C).

[Weight changes and the effect of anti-diabetes treatment in the first 5 years after diabetes diagnosis - secondary publication].

We monitored changes in patients' weight during the first 5 years after diabetes diagnosis. Data were from 711 newly diagnosed diabetic patients aged 40 or over managed in general practice. Patients whose only treatment was advice on diet generally maintained an initial weight loss of 5-7 kg over the 5 years. Patients receiving metformin or sulfonylureas maintained an average weight loss of 2-4 kg depending on age and sex, while an acceptable average glycaemic control was achieved. The results indicate that weight reduction is a practicable treatment in diabetic patients.

Autism Spectrum Disorder and Mental Health Comorbidity Leading to Prolonged Inpatient Admission.

Sam is a 6-year-old boy with a diagnosis of autism spectrum disorder (ASD) who recently relocated and has an appointment with you, his new pediatric clinician, to establish care. He was previously followed by a psychiatrist for 2 years for additional diagnoses of insomnia, bipolar disorder, anxiety, attention deficit hyperactivity disorder, and intellectual disability. He has tried and (apparently) failed multiple psychotropic trials including stimulants, nonstimulants, mood stabilizers, atypical antipsychotics, and nonbenzodiazepine hypnotics. He has a delayed sleep onset and frequent night awakenings each night for the past 3 months, during which he "screams, cries, and thrashes and can stay up for over an hour." His behaviors are described as irritable, self-injurious, and aggressive with no clear pattern of triggers according to his mother. He is nonverbal and communicates by leading and rarely pointing. The patient's current medication regimen includes clonidine 0.2 mg at night, lorazepam 1.5 mg as needed at night, olanzapine 5 mg twice daily, and diphenhydramine as needed for sleep/agitation. His mother is concerned that he is developing "tolerance" to the regimen and wants to wean him off some of the medications. His mother is struggling to take care of the patient given his worsening behavior and body habitus (body mass index >99%; z = 3.41).There is a family history of depression, anxiety, bipolar disorder, and autism. He has a 3-year-old sister, who is also diagnosed with ASD, though she is not as severely impacted. His mother's partner recently moved in along with 2 children of his own, aged 3 and 4 years. Sam attends a specialized school, where he receives behavior therapy and occupational therapy. He has undergone inpatient pediatric hospitalization twice, 1 time for 3 weeks and the other for 6 days, for aggressive behavior, and in both instances, he was discharged before inpatient psychiatric placement because of a lack of available beds.After urgent consultation with your local developmental and behavioral pediatrician, a slight reduction was made in the lorazepam because of concerns about tolerance and side effects. However, within a week of this, he was brought to the emergency department for continued self-injurious behavior and increased trouble with sleeping. His mother voiced concerns about his safety in the home, which were particularly related to aggression toward his younger sister. He was admitted to the pediatric inpatient floor for observation, and medication adjustment (increasing olanzapine), which was initially helpful in improving behavior, but mostly behavioral/environmental strategies were used to soothe him, including frequent wagon rides through the hospital corridors.Despite the patient being stable from the medical standpoint, Sam's mother did not feel comfortable taking him home. Social work contacted local community mental health services to pursue outpatient resources and respite care options and sought inpatient pediatric psychiatry. After several failed attempts to find placement, he remained in pediatric inpatient care for 1 and a half months with no acute medical interventions other than his oral medications.He was finally accepted to the in-state pediatric psychiatric facility when a bed was available. During his week-long stay, he had further medication adjustments with a decrease in olanzapine and optimization of his clonidine dose. During his psychiatric hospital stay, care coordination succeeded in arranging center-based applied behavior analysis interventions and respite care and parent training for his family. Sam began to show improvement in his overall agitation and aggression, requiring less clonazepam, and his mother then maintained outpatient follow-up.The day before discharge, you visit him in the hospital, and a medical student asks you why he was in the hospital for so long. How would you answer the question?

[Behavior of the body weight in 2261 maturity-onset diabetics under conditions of ambulatory care].

Of 2,261 maturity-onset-diabetics (970 males, 1,691 females) body weight, size and Broca-index were established at the beginning of the treatment, one year after the beginning of the treatment and at the date of analysis (x=5.7 years after the manifestation of diabetes). 72% of the females and 49% of the males had a Broca-index of more than 10 at the beginning of the treatment. The average loss of weight of the diabetics of adult type with overweight with a Broca-index of more than 5 was in the first year 7.6 kg in males and 5.2 kg in females. In the first year after beginning of the disease in the diet group and in the buformin group was achieved an average reduction of weight in males of about 7 kg and in females of about 6 kg. After the first year of treatment in the groups mentioned the body weight remained or rose to one kg. The patients treated with sulfonylureas--compared with the diet-biguanide group--showed in the first year of treatment, indeed, a loss of weight which was about 50% smaller, however, also in the following years (x=4.7) a further continuous reduction of weight could be recognized. The initial results and the late results in the treatment of elderly diabetics with overweight show that, compared with former years, partial success is to be achieved with reduction cures performed in outpatient departments. The importance of the reduction of weight in elderly diabetics for the improvement of the carbohydrate tolerance and the fat metabolism is emphasized.

Effects of aggressive approach to the multiple risk factors for diabetic nephro-pathy on proteinuria reduction in diabetes type 2 patients.

Dietary interventions with protein and salt restriction, good glucose control, smoking cessation, aggressive blood pressure control, good control of cholesterol and triglycerides, use of ACE inhibitors and ARBs can delay the progression of diabetic nephropathy. The aim of this study was to present the effects of aggressive treatment of the multiple risk factors for diabetic nephropathy on proteinuria in patients with type 2 diabetes. In this study we included 15 patients with diabetes type 2 and insufficient regulation of glycaemia. The patients were followed for three months period. Glycated haemoglobin (HbA1c), fasting plasma glucose (FPG), postprandial plasma glucose (PPG), blood pressure, cholesterol and triglycerides and proteinuria were followed prior and after the study. Prior the study patients were treated with premix insulin divided in two daily doses + metformin after the lunch and they had insufficient regulation of glycaemia. During the study patients were treated with one daily dose of basal insulin, three doses of metformin (2550 mg), one daily dose of atorvastatin (20 mg) and one daily dose of ramipril (5 to 10 mg). Doses of insulin were titrated separately for each patients (0,7-1,0 IU/kg). Patients were advised to start with lifestyle modification, increased physical activity and dietary interventions with protein and salt restriction, energy restricted diet and smoking cessation. A total of 20 patients (male 12 and female 8) with diabetes type 2 were studied. The mean age of the subjects was 53+/-5,25 years. The mean diabetes duration was 4,05+/-1,96 years. The mean body mass index decreased from 28,1+/-1,67 kg/m2 to 25,9 +/-1,22 kg/m2 after the study. Mean HbA1c decreased from 8,82 +/- 0,53 % to 7,15 +/- 0,23 % (p<0,05). Mean fasting glycemia decreased from 8,79+/-0,58 mmol/dm3 to 7,03+/-0,18 mmol/dm3 (p < 0,05). Mean postmeal glycemia decreased from 9,93 +/- 0,77 mmol/dm3 to 7,62 +/- 0,42 mmol/dm3 (p<0,05). The mean cholesterol level decreased from 7,99 +/-0,64 mmol/dm3 to 5,93 +/- 0,65 mmol/dm3 (p<0,05). The mean triglicerides level decreased from 4,05 +/- 0,97 mmol/dm3 to 1,96 +/- 0,24 mmol/dm3 (p<0,05). The significant decrease of proteinuria was recorded, prior the study the mean albuminuria was 1,05 +/- 0,31 g/dm3 and after the study was 0,07 +/- 0,145 g/dm3 (p<0,05). Mean blood pressure prior the study was 153+/-8,69/91,5 +/- 3,78 mm Hg (p<0,05), after the study was 125 +/- 6,32/ 79,25+/-3,26 mmHg. Effective control of glycaemia, blood pressure, cholesterol and triglycerides, use of ACE inhibitors, dietary interventions with protein and salt restriction, smoking cessation, can delay the progression of nephropathy in type 2 diabetes.

Natural history of diabetes presenting age 40-69 years: a prospective study of the influence of intensive dietary therapy.

Two hundred and twenty-three newly-diagnosed symptomatic diabetic patients with onset age 40-69 years enrolled in a prospective study of intensive dietary management of diabetes were observed for a period of six years and the data obtained is analysed. The variables studied were weight and fasting levels of plasma glucose and insulin, and of serum total cholesterol and triglyceride. These tests were monitored throughout the study and in addition the oral glucose tolerance test was analysed at entry to the study, after six months intensive dietary management and again after 72 months. Blood pressure, electrocardiogram and the presence of posterior tibial artery pulsation were recorded at entry to the study and at 36 months and 72 months. Approximately 80 per cent of the patients were managed solely by dietary restriction for the entire six years, but 25 patients received oral hypoglycaemic drugs and 26 required insulin treatment. Weight, and fasting glucose and triglyceride values fell in the first few months of intensive dietary management. Analysis of possible risk factors in survivors and patients dead at six years showed no significant differences, apart from a higher mean age at diagnosis in those who died. During the six years of intensive dietary management the mortality from all causes in these diabetic patients was no greater than that for the general population of Northern Ireland.