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Studies with school aged children of several communities of the United States have indicated that between one and two percent of them should be considered hypertensive. These findings contradict previous statements of a very rare incidence of hypertension in childhood. Some studies show that children of Black and Hispanic American ancestry, especially females, have a higher incidence of hypertension. The highest incidence of hypertensive children was related to a history of familial hypertension and obesity. In children less than three years of age and in infants, hypertension is less frequent. A disease of the urinary apparatus (nephropathy) or of the cardiovascular system (aorta coarctation) can often be identified as the primary cause of the hypertension. Less frequent is hypertension sustained by adrenal cortical dysfunction or a neoplasm of the adrenal medulla. Hypertensive crisis also frequently develops in children after thermal injury or renal transplant. In children, the use of antihypertensive drugs should be reserved for cases where the disease is very severe. Effective regulation of dietary and hygienic habits should be recommended, particularly for those cases of "mild" or "borderline" essential hypertension.
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PMID:Considerations of the renin-angiotensin aldosterone system in the pathogenesis of hypertension in infancy. 675 76

The National Commission on Sleep Disorders Research, in its report to Congress, concluded that the primary care community generally does not understand sleep disorders. Obstructive sleep apnea carries a risk of substantial morbidity and mortality. Excessive daytime sleepiness results from fragmented sleep and microarousals associated with apneic events. It causes poor work performance and increases the incidence of automobile accidents due to driving while drowsy. The commission estimates that the loss of productivity in the United States from excessive daytime sleepiness is more than $20 billion per year. Obstructive sleep apnea is strongly associated with hypertension, myocardial infarction, and stroke. Risk factors for obstructive sleep apnea include male sex, obesity, older age, craniofacial anomalies, and familial risk. Treatment is based on documenting the disorder by polysomnography. Medical management of the syndrome includes weight loss and nasal continuous positive airway pressure. A network of follow-up and support is necessary to maintain compliance. Surgical treatment is reserved for those for whom nasal airway pressure treatment fails. A surgical protocol is presented that demonstrates efficacy equal to nasal airway pressure treatment. Primary care physicians should assume the responsibility of identifying patients at risk for obstructive sleep apnea and refer them appropriately.
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PMID:Obstructive sleep apnea. Trends in therapy. 772 98

Diagnostic or therapeutic arterial catheterization may be complicated by postcatheterization pseudoaneurysm. Pseudoaneurysms have generally been treated surgically, but more recently, encouraging results with duplex-guided compression therapy (DGCT) of pseudoaneurysms have been reported from university hospitals. We reviewed our experience with DGCT to assess the applicability of DGCT in a community hospital setting. Sixty-two patients presented with 63 symptomatic postcatheterization pseudoaneurysms between January 1, 1990, and December 31, 1993. Prior to October 28, 1991, all pseudoaneurysms were treated surgically. Subsequently we initiated DGCT as primary treatment for pseudoaneurysms, reserving surgery for DGCT failures and unstable patients. DGCT patients were indistinguishable from primary surgery patients, and the number of pseudoaneurysms treated did not appear to increase during the study period. DGCT was initially successful in 27 (75%) of 36 patients. Three pseudoaneurysms recurred, yielding cumulative success in 24 (67%) of 36 patients. Three of 12 DGCT failures were due to patient intolerance. DGCT was unsuccessful in three of four intra-aortic balloon pump (IABP)-associated pseudoaneurysms. There was some variation in pseudoaneurysm volume between the successful and failed groups, and a trend toward failure with larger pseudoaneurysm was not significant (13 vs. 6 cm3, p > or = 0.25). DGCT failure appears more likely in post-IABP pseudoaneurysms and possibly with larger pseudoaneurysms. Anticoagulation, type of procedure (exclusive of IABP), obesity, and other patient characteristics examined did not appear to predict success or failure of DGCT. Treatment was reserved for symptomatic patients throughout the period of study and there was no evidence that patients were more likely to be treated for pseudoaneurysms after DGCT was initiated. We conclude that DGCT is usually successful and is appropriate primary treatment for all symptomatic postcatheterization pseudoaneurysms in stable patients.
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PMID:Color duplex-guided compression therapy for postcatheterization pseudoaneurysms in a community hospital. 868 93

The actual tendency in the care of obese patients is the association of dietetic information with an eating behavior therapy. Studies attempting to attribute the origin of obesity to psychiatric pathologies are contradictory. We studied whether certain eating disorders are more specific to a personality type. We studied eating disorders with the Eating Disorder Inventory (EDI) test in 281 obese women compared to 252 age-matched non-obese women. Both obese patients and non-obese volunteers were divided into four groups depending upon their personality (PERSONA test). This test defines four types of personality, based on the level of emotion (expansive or reserved) and the degree of power (dominant or consenting). According to our study, eating disorders vary between the four personality groups and were significantly higher in the facilitating group (consenting and expansive) compared to the three other obese groups. Neither promoting (expansive and dominant) nor controlling obese patients (dominant and reserved) present eating disorders. The analyzing obese patients (reserved and consenting) are reticent when it comes to consulting (18%) since they distrust others. Analyzing obese patients present an interpersonal distrust and an interoceptive awareness. The group which presents most eating disorders is that of facilitating obese patients (consenting and expansive). These present eating disorders of the compulsive types favored by interoceptive awareness, body dissatisfaction, ineffectiveness, and maturity fears. The diversity, even the absence, of eating disorders brought to evidence by our tests based upon different personality types should allow better understanding of the psychological and behavioral causes of weight gain and the means for improving compliance in the following of an obese patient.
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PMID:Personalities and alimentary behaviors in obese patients. 921 51

The major goal of the evaluation and management of DLP in children is to provide safe and effective therapy with lifestyle modification. There is a strong rationale for the initiation of DLP treatment in childhood to limit the earliest stages of atherosclerosis, to establish lifelong lifestyle changes in diet and activity, and to limit the acquisition of additional CVD risk factors such as smoking and obesity. The NCEP has recommended screening for children with a parent with total cholesterol of 240 mg/dL or greater or a parent or grandparent with onset of CVD before age 55 years. Clinical evaluation and management are based on an LDL-C level of 130 mg/dL or greater. This approach to screening has a low sensitivity to identify children with DLP. Initial therapy is with a step 1 diet followed by the step 2 diet if necessary. Medications are reserved for older children with LDL-C of 190 mg/dL or greater after diet therapy or 160 mg/dL or greater with other CVD risk factors.
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PMID:Evaluation and management of dyslipoproteinemia in children. 978 58

Obesity management includes primary weight loss, prevention of weight regain, and the management of associated risk factors, such as smoking, hyperlipidaemia and hypertension. All these require lifestyle modification. The success or failure of management will depend on the characteristics of both the patient and the physician (or therapeutic team). Thus, direct statistical comparisons between methods of management may be misleading. Weight loss of 5-10% (usually 5-10 kg and equivalent to 5-10 cm waist reduction for most patients) is generally achievable within 3-4 months. Attempts to achieve weight loss over longer periods of time are usually unsuccessful. Improved clinical, symptomatic and biochemical benefits are very significant with this degree of weight loss. It is therefore unreasonable to pursue an 'ideal' bodyweight. In reported studies, the weight decrease over the first 3-4 months represents the total weight loss. Data collected after this time reflect both the initial weight loss and the ability of the patient and the programme to maintain weight loss. Many reports and study designs do not make this distinction. The principal goal of weight management, whether in primary prevention or in treatment of the obese, is weight maintenance. This goal has to be viewed in the context of a normal tendency to gain weight through adult life. In good hands, dietary and behavioural techniques can maintain significant weight loss for 1 year or longer in about 40% of patients. This increases to about 70% for patients receiving appetite modifying drugs; professional resource requirements are also lower. Surgical approaches are reserved for those with more serious clinical risks. Weight loss in individuals with non-insulin dependent diabetes mellitus (NIDDM) can be achieved in newly diagnosed patients and non-diabetics with comparable success. The goal of interventions in established NIDDM patients should be improved weight maintenance evaluated over 1-2 years, not acute loss achieved in 3 months.
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PMID:Obesity--what are the current treatment options? 979 77

The purpose of this article is to review the data from pharmacotherapeutic and surgical intervention studies for the management of obesity. Clinical outcomes assessed include weight changes over time and the effects of weight loss on blood pressure, serum lipid profiles and blood glucose control. Quality of life and economic data have been incorporated where available. Double-blind, randomised controlled trials were used preferentially over shorter term open studies. The literature evaluation was based on a Medline search of published data between January 1990 and January 1998. Obesity affects 65 million adults in the US. Estimates based on 1990 data suggest that obesity and comorbid illness contributed to $US46 billion in direct costs and $US23 billion in indirect costs in the US. Obesity is a chronic condition which requires long term management. The risk of developing cardiovascular disease, hypertension, type 2 (non-insulin-dependent) diabetes mellitus, osteoarthritis, Pickwickian syndrome and cancer is increased in the obese population, resulting in excess morbidity and mortality. There are no long term prospective studies that have demonstrated that weight reduction in obese patients improves survival. However, on the basis of epidemiological data using the prevalence of disease and associated body mass index, it is generally accepted that weight reduction of 5 to 10% in obese patients is associated with significant health benefits. Current treatment modalities include diet and behaviour modification, exercise and, where indicated, pharmacological intervention. Surgical intervention is reserved for the clinically severe obese patient [body mass index (BMI) > 40 kg/m2]. Many studies have demonstrated weight loss and improved metabolic fitness over 6 to 12 months. Few studies have been conducted over a longer period. Limited data are available regarding reduced morbidity and mortality, improved quality of life and functional or employment status and even fewer have incorporated any economic assessments of the impact of medical or surgical intervention. Although prospective data have demonstrated reduced morbidity following surgical intervention, only retrospective data have demonstrated reduced mortality. Studies of new drugs and interventions under development should demonstrate long term safety and efficacy in terms of sustained weight loss and subsequent weight maintenance. Future studies should incorporate assessment of patient perceived satisfaction with weight loss, health status and quality-of-life evaluations and pharmacoeconomic data to aid clinicians in the decision-making process in terms of weight management of their obese patients.
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PMID:Outcomes of pharmacological and surgical treatment for obesity. 1018 66

Obesity increases the risk of several serious health problems, including heart disease, type II diabetes mellitus, hypertension, and osteoarthritis. Patients taking certain psychotropic medications may gain a significant amount of weight (as much as a 5% increase in body weight within 1 to 2 months), placing them at risk for obesity. Body weight monitoring and prudent drug selection are the best approaches to preventing weight gain in patients taking psychotropic drugs. When weight gain (> 5% of initial body weight) is unavoidable, intervention counseling should begin. Nonpharmacologic measures for managing weight gain include a balanced deficit diet of 1000 calories and higher, depending on the patient's weight; 30 to 60 minutes of physical activity daily; and behavioral training to restrain excess caloric intake. Each of these measures requires a considerable commitment on the part of the patient and works best with support from the physician and weight-loss support groups. Drug therapy for weight loss is available (at present, sibutramine is the only approved appetite suppressant in the United States); however, for most patients already being treated with a psychotropic agent, the risks (such as drug interactions, adverse events, compliance problems) of adding an antiobesity agent probably outweigh the benefits. Surgical intervention for obesity should be reserved for morbidly obese patients whose disease is intractable to medical therapy.
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PMID:Nonpharmacologic and pharmacologic management of weight gain. 1054 40

Hypertension is currently defined in terms of levels of blood pressure associated with increased cardiovascular risk. A cut-off of 140/90 mm Hg is accepted as a threshold level above which treatment should at least be considered. This would give a prevalence of hypertension of about 20% of the adult population in most developed countries. Hypertension is associated with increased risk of stroke, myocardial infarction, atrial fibrillation, heart failure, peripheral vascular disease and renal impairment. Hypertension results from the complex interaction of genetic factors and environmental influences. Many of the genetic factors remain to be discovered, but environmental influences such as salt intake, diet and alcohol form the basis of nonpharmacological methods of blood pressure reduction. Investigation of the individual hypertensive patient aims to identify possible secondary causes of hypertension and also to assess the individual's overall cardiovascular risk, which determines the need for prompt and aggressive therapy. Cardiovascular risk can be determined from (i) target organ damage to the eyes, heart and kidneys; (ii) other medical conditions associated with increased risk; and (iii) lifestyle factors such as obesity and smoking. Secondary causes of hypertension are individually rare. Screening tests should be initially simple, with more expensive and invasive tests reserved for those in whom a secondary cause is suspected or who have atypical features to their presentation. The main determinants of blood pressure are cardiac output and peripheral resistance. The typical haemodynamic finding in patients with established hypertension is of normal cardiac output and increased peripheral resistance. Treatment of hypertension should initially use nonpharmacological methods. Selection of initial drug therapy should be based upon the strength of evidence for reduction of cardiovascular mortality in controlled clinical trials, and should also take into account coexisting medical conditions that favour or limit the usefulness of any given drug. Given this approach, it would be reasonable to use a thiazide diuretic and/or a beta-blocker as first-line therapy unless there are indications to the contrary. Individual response to given drug classes is highly variable and is related to the underlying variability in the abnormal pathophysiology. There are data to suggest that the renin-angiotensin system is more important in young patients. The targeting of this system in patients under the age of 50 years with a beta-blocker (or ACE inhibitor), and the use of a thiazide diuretic (or calcium antagonist) in patients over 50 years, may enable blood pressure to be controlled more quickly.
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PMID:Pathoaetiology, epidemiology and diagnosis of hypertension. 1067 92

Obesity represents one of the most important treatable causes of mortality and morbidity facing the primary care physician. Approximately one of every three U.S. adults is overweight or obese, leading to more than 300,000 preventable deaths each year. Because it is a multifactorial disorder involving food intake, physical activity, metabolism, and genetic factors, obesity is best treated with a coordinated approach. Diet and exercise remain the best initial treatment focus. Orlistat and sibutramine are recently developed medications reserved for obese patients who fail conservative therapy. Surgical remedies are indicated in limited circumstances for morbidly obese individuals. As primary care physicians, obstetrician/gynecologists are ideally positioned to motivate, evaluate, and treat overweight patients.
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PMID:The evaluation and treatment of the overweight patient. 1107 34


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