The pandemic of overweight and obesity continues to rise in an alarming rate in western countries and around the globe representing a major public health challenge in desperate need for new ...strategies tackling obesity. In the United States nearly two thirds of the population is overweight or obese. Worldwide the number of persons who are overweight or obese exceeded 1.6 billion. These rising figures have been clearly associated with increased morbidity and mortality. For example, in the Framingham study, the risk of death increases with each additional pound of weight gain even in the relatively younger population between 30 and 42 years of age. Overweight and obesity are also associated with increased co-morbid conditions such as diabetes, hypertension and cardiovascular disease as well as certain types of cancer. In this review we discuss the epidemic of obesity, highlighting the pathophysiologic mechanisms of weight gain. We also provide an overview of the assessment of overweight and obese individuals discussing possible secondary causes of obesity. In a detailed section we discuss the currently approved therapeutic interventions for obesity highlighting their mechanisms of action and evidence of their efficacy and safety as provided in clinical trials. Finally, we discuss novel therapeutic interventions that are in various stages of development with a special section on the weight loss effects of anti-diabetic medications. These agents are particularly attractive options for our growing population of obese diabetic individuals.
Abstract only
Background
. Chronic kidney disease is recognized as an independent cardiovascular disease risk state, particularly in the elderly, and has been defined by levels of estimated ...glomerular filtration rate (eGFR) and markers of kidney damage. The relationship between the presence of chronic kidney disease (CKD) and premature cardiovascular disease (CVD) has not been previously described.
Methods.
Volunteers at risk for chronic kidney disease completed surveys regarding past medical events and underwent blood pressure, and laboratory testing. Estimated GFR was computed using a 4-variable equation and the urine albumin:creatinine ratio (ACR) was measured. Data were stratified by decile of age. Premature CVD was defined as a myocardial infarction (MI) or stroke < age 55 years in men and <65 years in women. Mortality was ascertained by linkage to national data systems.
Results.
Of 34,614 the mean age was 46.5 γ 11.5 years, 68.5% were female, 36.2% African American, and 23.0% had diabetes. A total of 21.5% were found to have CKD (defined as eGFR < 60 ml/min/1.73 m2 and or ACR >= 30 mg/g), with the ACR and eGFR being the dominant positive screening tests for CKD in the younger and older age deciles, respectively, p<0.0001 for both trends. The composite rates of premature MI, stroke, or death for those with and without CKD were 8.0 and 3.9%, p < 0.0001. Multivariate analysis found CKD, OR = 1.43, 95% CI 1.26 –1.61; hypertension OR = 1.65, 95% CI 1.43–1.89; diabetes, OR = 1.94, 95% CI 1.72–2.19; smoking, OR 1.87, 95% CI 1.62 – 2.15; female gender, OR=1.64, 95% CI 1.45–1.87; and less than high school education, OR=1.56, 95% CI 1.35–1.82, as the most significant predictors of premature CVD or death (all p <0.0001). Survival analysis found those with premature MI or stroke and CKD had the poorest short term survival over the next three years after screening, p<0.0001.
Conclusions:
Chronic kidney disease is an independent predictor of premature MI, stroke, and death. These data suggest the biologic changes that occur with CKD promote CVD at an accelerated rate that cannot be fully explained by conventional risk factors. Screening for CKD by using both the ACR and eGFR can identify individuals at high risk for premature CVD and near term death.
A 30-year-old man presented to the emergency department of another institution with recurrent episodes of generalized tonic-clonic seizures. He was found to be hypocalcemic and was treated with an ...intravenous infusion of calcium followed by Dilantin. A computed tomography scan of the head was obtained, and the patient was transferred to our institution for neurosurgical evaluation and possible intervention of what was thought to be bilateral intracranial hemorrhages. After further evaluation at our institution, the diagnoses of hypoparathyroidism associated with hypocalcemic seizures and basal ganglia calcifications were established on both clinical and biochemical grounds. This case report discusses the clinical presentation, pathogenesis, diagnostic work-up, and management of hypoparathyroidism and associated seizures, highlighting the possible diagnostic and therapeutic pitfalls that are most pertinent to the emergency physician.
Bronchiectasis is characterized by permanent destruction of the airways that presents with productive cough, as well as bronchial wall thickening and luminal dilatation on computed tomographic (CT) ...scan of the chest; it is associated with high mortality. Accumulating data suggests higher rates of bronchiectasis among the HIV-positive population. This case series involves 14 patients with bronchiectasis and HIV followed at two major urban institutions from 1999 to 2018. Demographics, clinical presentation, microbiology, radiographic imaging, and outcomes were collected and compiled. Mean age was 42 years (range 12-77 years). 36% had a CD4 count greater than 500 cells/mm3, 28% had a CD4 count between 200 and 500 cells/mm3, and 36% had AIDS. 43% were treated for Pneumocystis jiroveci pneumonia (PJP) and 50% for Mycobacterium avium complex (MAC) infection. 21% had COPD, 7% had asthma, and 7% had a history of pulmonary aspergillosis. Two patients were followed up by pulmonary services after diagnosis of bronchiectasis on CT. The timeline of the follow-up in these cases was within months and after three years respectively. It is posited that the prevalence of bronchiectasis in HIV patients may be underestimated. Improving recognition and management of bronchiectasis could help diminish rehospitalization rates.
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