Catherine Cordonnier, M.D.

• Professor of Hematology
• Hematology Oncology
• Universit? Paris 12
• Head
• Clinical Hematology Department
• Henri Mondor University Hospital
• Cr?teil, France

Awareness of the Needs of Cancer Survivors Since 2006 rumi herbals discount hoodia 400mg with amex, Nekhlyudov said there has been an increase in programs dedicated to cancer survivorship juvena herbals buy on line hoodia. Public awareness has also been raised as public ofcials herbals baikal best hoodia 400mg, actors herbalstarcandlescom generic hoodia 400mg overnight delivery, and newsmakers have shared their survivorship experiences lotus herbals 4 layer facial 400mg hoodia for sale. In addition herbs nursery generic hoodia 400 mg otc, information about survivorship is increasingly available through books (Coscarelli et al. However, Nekhlyudov said that information about survivorship has not been uniformly transferred to community and academic health care settings. Ganz added that although some public attention is paid to the concerns of cancer survivors, many survivors remain unaware of their risk of recurrence and late efects, and have no plan for follow-up care. In discussing the need for survivorship care plans, Ganz indicated that clinicians can beneft from knowing the types of cancer treatment the survivor had, the potential late efects associated with those treatments, and their expected time course. For example, if a survivor had radiation directed to the chest, any clinician seeing the survivor needs to know about the risk of cardiac late efects. The risks of late efects need to be communicated to the survivor as well, in a way that he or she can understand, said Ganz. Recommendation 2: Patients completing primary treatment should be provided with a comprehensive care summary and follow-up plan that is clearly and effectively explained. Recommendation 3: Health care providers should use systemically developed evidence-based clinical practice guidelines, assessment tools, and screening instruments to help identify and manage late effects of cancer and its treatment. Existing guidelines should be refned, and new evidence-based guidelines should be developed through publicand private-sector efforts. Recommendation 8: Employers, legal advocates, health care providers, sponsors of support services, and government agencies should act to eliminate discrimination and minimize adverse effects of cancer on employment, while supporting cancer survivors who have shortand long-term limitations in ability to work. Recommendation 9: Federal and state policy makers should act to ensure that all cancer survivors have access to adequate and affordable health insurance. Insurers and payors of health care should recognize survivorship care as an essential part of cancer care and design benefts, payment policies, and reimbursement mechanisms to facilitate coverage for evidence-based aspects of care. New research initiatives focused on cancer patient follow-up are urgently needed to guide effective survivorship care. She said an important fnding in From Cancer Patient to Cancer Survivor was that the Chronic Care Model applies to the care of cancer survivors because nearly all of them need chronic monitoring and follow-up. The model posits that the quality of care benefts from an interaction between the community. Ganz noted that the advent of many electronic tools should make these communications easier than they were more than a decade ago. In developing a survivorship care plan, Ganz said there is some uncertainty about when the process should start. For example, when providing follow-up for a patient with a high-grade lymphoma, the clinician might be inclined to wait 12 to 18 months in case the cancer recurs. For patients with breast cancer, some clinicians are comfortable preparing a care plan when women have fnished their primary treatment and are starting endocrine therapy. Ganz noted that this represents a good time to talk about wellness and adherence to medications. Nekhlyudov acknowledged that the provision of a survivorship care plan is not routine among clinician practices. She said the reasons for the lack of widespread adoption include the time and labor needed to prepare care plans and a lack of research on the impact of survivorship care plans on patient outcomes (Brennan et al. Clinical Practice Guidelines for Cancer Survivorship Care Ganz said that in 2006, there were few clinical practice guidelines on follow-up care for survivors, and health care professionals generally lacked survivorship education and training. Ganz observed that while progress has been made in this regard, professional education and training in survivorship 4 See. Nekhlyudov said that, increasingly, guidelines have become evidence based, and eforts are under way to harmonize international guidelines. Nonetheless, she said many diseasebased guidelines do not fully recognize and highlight the complex needs of cancer survivors. Nekhlyudov identifed organizations leading the way in the development of survivorship care guidelines. Quality Assessment and Models of Care Nekhlyudov said that assessing the quality of survivorship care remains a work in progress, with a need for further research and development. However, the stratifcation of survivors into low-, intermediate-, or high-risk categories has been helpful in the design of models of follow-up care, said Ganz. She explained that the consensus committee concluded that cancer care is often not as patient-centered, accessible, coordinated, or evidence-based as it could be. A conceptual framework was developed that illustrates the importance of patient-centered care in the delivery of high-quality cancer care (see Figure 3). In her experience as a member of a committee in Massachusetts working to defne quality metrics to integrate into the state plan, she said it was difcult to fnd outcomes that were clinically meaningful, measureable, and available. Nekhlyudov said it will be instructive to see what works at the state level and whether successes can be replicated across the country. She added that eforts in this area are in progress and there has been movement toward multiprofessional education at many medical schools. Employment Challenges Nekhlyudov cited some of the many studies on the topic of employment-related issues for cancer survivors (Ekwueme et al. Many studies have addressed the implications of cancer for work, employment, and physical function, but she concluded that there is more work to be done in this area. Without such protection, Ganz said, even patients with a generous insurance plan could easily meet a $1 million cap after a cancer diagnosis. Survivorship Research Nekhlyudov reported on a marked increase in survivorship research published from 1984 to 2010 (Harrop et al. However, she emphasized that there is a lack of population-based research in this area. She added that much of the research has focused on quality of life, but other important domains of cancer survivorship are not yet well addressed. Nekhlyudov said that in light of the increasing number of long-term cancer survivors, additional investments in research are imperative. Mayer said there is some evidence that progress is being made in delivering tier one services to survivors. However, she said there has been little success in delivering tier two and three services. This practice still remains to some extent, Mayer said, but as the population of cancer survivors ages and the prevalence of comorbidities rises, oncologists will no longer be able to manage all care. Nurse practitioners will, by necessity, extend and enhance the care that needs to be provided in any delivery model, including tasks such as clinical management of diabetes, hypertension, and other chronic diseases, said Mayer. Mayer discussed a recent literature review on the relationship between primary care clinicians and cancer specialists (Dossett et al. Mayer said that within complex health care systems, there are too many failures in handofs and transitions. Mayer said that primary care clinicians do believe they have Copyright National Academy of Sciences. Mayer concluded by listing key questions that need to be answered in survivorship care: What care is neededfi She suggested optimizing the functionality and use of data and electronic tools. To extend and enhance the care delivery system, Mayer emphasized a need to fully use advanced practice clinicians for survivorship care, as well as nurse and lay navigators. She added that care has moved from the hospital, to outpatient settings, and now into the home, so family members will need support, and those without home support will need attention. Lateand Long-Term Health Risks Kevin Oefnger, director of the Duke Center for Onco-Primary Care and the Duke Cancer Institute Cancer Supportive Care and Survivorship Center, summarized the health risks that cancer survivors face following treatment and discussed the research on interventions for improving the physical well-being of cancer survivors. Tese deaths are largely attributable to aging and often a common insulin-resistance pathway that leads to both cardiovascular disease and breast cancer, and generally not the late efects of cancer therapy (Hanrahan et al. To further illustrate the physical issues afecting cancer survivors, Oefnger summarized research fndings related to subsequent primary cancers and cardiovascular disease, which are the greatest contributors to morbidity and premature mortality apart from the primary cancer, as well as accelerated aging. Subsequent Cancers Oefnger said one out of every fve new cancers diagnosed in the United States is a second, third, or fourth cancer for the patient (Travis et al. He said the factors contributing to a subsequent primary cancer include unhealthy behaviors. Oefnger said studies involving patients with the highest risk for lifestyle-related second primary cancers (individuals with head and neck cancer) indicated that: Copyright National Academy of Sciences. Oefnger concluded that lung cancer screening should be considered for this very high-risk population. Aging is also a risk factor for a second primary cancer, Oefnger reported (Donin et al. He said a modeling study indicated that among women with a primary breast or colorectal cancer, the 10-year cumulative risk of a second primary cancer increases with age and is higher than that expected in the general population (Moitry et al. At ages 75 and older, approximately 10 percent of women with either primary breast or colorectal cancer would experience a second cancer. Among men with a primary prostate or colorectal cancer, the 10-year cumulative risk of a second primary cancer increases to about 16 percent after age 75, and men with a primary colorectal cancer face a 10-year cumulative risk of a second primary cancer of more than 20 percent at ages 65 and older, Oefnger said (Moitry et al. Other studies have shown the role of genetics in second primary cancers, said Oefnger. One study showed that among patients diagnosed between ages 15 to 50, the risk of second primary cancers did not change much over diferent eras of therapy. He noted that these patients often have third, fourth, and subsequent primaries (van Eggermond et al. According to Oefnger, studies show a marked elevation in risk of coronary artery disease among both men and women treated with mediastinal radiotherapy. The risk for women aged 35, 45, and 50 is as high as for men of the same age, and there is a one in fve chance of having symptomatic coronary artery disease by 20 years following moderate dose radiation to the mediastinal area, he said (Reinders et al. Over the next 10 years, she has an absolute risk of about 10 to 12 percent of having a serious cardiac event (van Nimwegen et al. The older the patient was at the time of treatment, especially with multiple comorbidities, the higher the risk was of cardiac death. Among the largest population of cancer survivors, women treated for breast cancer, Oefnger said studies show that more than half of those ages 65 or older have hypertension or lipid disorders, and a sizable fraction have diabetes (Chen et al. Hypertension, either before, during, or after cancer therapy, is the single most important predictor of heart failure in breast cancer survivors treated with anthracyclines and trastuzumab, he noted (Chen et al. Oefnger emphasized that for women with breast cancer, continued monitoring of hypertension, diabetes, and lipid disorders is important for their longevity and quality of life, and that standardized approaches to managing these common comorbidities are needed. Oefnger added that for most cancer survivors, hypertension is now recognized as the single most important driver of long-term cardiovascular outcomes, both heart failure and coronary artery disease. He also noted that prevention and monitoring guidelines for cardiovascular dysfunction were recently developed (Armenian et al. Accelerated Aging Oefnger said the acceleration of aging varies among cancer survivors and across body systems. He said a useful geriatric assessment tool, the defcit-accumulation frailty index, includes a variety of domains. In a study that applied this index to a cohort of 500 cancer patients ages 65 and older, half of the patients were classifed as non-frail, 197 (39 percent) were pre-frail, and 52 (11 percent) were frail (Cohen et al. This same trend of higher risk of death among those categorized as frail has also been observed in adult survivors of childhood cancer, he noted (Ness et al. Research on Interventions for Improved Physical Well-Being Oefnger discussed research on strategies for mitigating lateand long-term physical health risks in adult cancer survivors. Oefnger added that more research on efective strategies for improving screening rates among high-risk survivors is needed, as is more evidence to support risk-stratifed surveillance. He emphasized that risk prediction models incorporating treatment exposures are needed for a range of outcomes so that absolute risks can be calculated and used to inform patients and plan survivorship care.

Syndromes

• Bleeding
• Metals (chromium/chromates, platinum salts, nickel compounds, copper, lead, cis-platinum)
• Children: 34 to 220
• Mumps
• Muscular dystrophy
• Medicines used to treat diarrhea, if they are taken too often
• Vomiting blood (sometimes)
• Salicylates (aspirin-like compounds)
• Time of the bite
• Bradycardia-tachycardia -- alternating slow and fast heart rhythms

Excessively tall quantum herbals discount 400 mg hoodia fast delivery, flat herbals and liver damage buy discount hoodia 400 mg online, or inverted T waves occurring with symptoms such as chest pain indicate ischemia herbs to grow indoors buy hoodia 400mg low price. Imaginary lines drawn from each of the leads intersect the center of the heart and form a diagram known as the hexaxial reference system herbals stock photos 400mg hoodia sale. This axis shift may result from Extreme axis Left axis fibrosis of the anterior deviation deviation fascicle of the left bundle branch or thickness I I of the left ventricular wall top 10 herbs purchase cheapest hoodia and hoodia, which increases by 25% between ages aV 30 and 80 himalaya herbals wiki cheap 400mg hoodia with mastercard. If lead I is upright and lead aV Memory F jogger points down, left axis deviation exists. A more precise axis calculation, the degree method gives an exact degree measurement of the electrical axis. Plot this information on the hexaxial diagram to determine the direction of the electrical axis. Remember that electrical activity in the heart swings away from areas of damage or necrosis, so the damaged part of the heart will be the last area to be depolarized. Angina During an episode of angina, the myocardium demands more oxygen than the coronary arteries can deliver. You may hear the term stable angina applied to certain conditions and unstable angina applied to others. In stable angina, pain is triggered by exertion or stress and is usually relieved by rest. Unstable angina, which is one of the components of acute coronary syndrome, is more easily provoked, usually waking the patient. The pain is generally more intense and lasts longer than the pain of stable angina. In this disorder, either the left or the right bundle branch fails to conduct impulses. A bundle-branch block that occurs farther down the left bundle, in the posterior or anterior fasciculus, is called a hemiblock. Others are monitored only to detect whether they progress to a more complete block. Impulsive behavior In a bundle-branch block, the impulse travels down the unaffected bundle branch and then from one myocardial cell to the next to depolarize the ventricle. Because this cell-to-cell conduction progresses much more slowly than the conduction along the specialized cells of the conduction system, ventricular depolarization is prolonged. After you identify a bundle-branch block, examine lead V1, which lies to the right of the heart, and lead V6, which lies to the left of the heart. The R wave is followed by an S wave, which represents left ventricular depolarization, and a tall R wave (called R prime, or R), which represents late right ventricular depolarization. The impulse then Block crosses the 1 2 interventricular septum to activate the right ventricle. However, that deflection is called a secondary T-wave change and is of no clinical significance. A small Q wave is followed by depolarization of the left ventricle, which produces a tall R wave. Then the impulse activates the interventricular septum from right to left, the opposite of normal activation. A tall, notched R wave, or a slurred one, is produced as the impulse spreads from right to left. Changes shown by the leads that reflect electrical activity in damaged areas are shown on the right of the illustration. Changes on damaged side Injury Infarction Reciprocal changes Ischemia Injury Infarction Ischemia Zone of infarction the area of myocardial necrosis is called the zone of infarction. Scar tissue eventually replaces the dead tissue, and the damage caused is irreversible. Q waves in other leads suggest the outermost area is called the zone of ischemia and results cardiac disease, such as from an interrupted blood supply. However, if symptoms persist for more than 6 hours, little can be done to Mixed prevent necrosis. Thrombolytic therapy may also be prescribed to dissolve a supply to the heart of a thrombus occluding a coronary artery. Match the lead changes in the second column with the affected wall in the first column and the artery involved in the third column. Using the four-quadrant method for determining the electrical axis, you determine that he has a: A. Using the four-quadrant method for determining electrical axis, you determine that he has a: A. A 45-year-old patient is admitted to your floor for observation after undergoing cardiac catheterization. A patient with heart failure is transferred to your unit from the medical-surgical floor. Using the 8-step method of rhythm strip interpretation, what should you do firstfi A 76-year-old patient with heart failure is receiving furosemide (Lasix) 40 mg I. An 80-year-old patient with a history of atrial fibrillation is admitted with digoxin toxicity. When you assess his rhythm strip using the 10-times method, you note that his heart rate is 40 beats/ minute. A patient with a history of paroxysmal atrial tachycardia develops digoxin toxicity. A patient is admitted to your telemetry unit with a diagnosis of sick sinus syndrome. Which medication should you keep readily available to treat a symptomatic eventfi Sinus tachycardia is a normal response that typically abates after the first 24 hours. Sinus tachycardia is a poor prognostic sign because it may be associated with massive heart damage. A patient who has been taking digoxin (Lanoxin) suddenly develops the rhythm shown below. As you perform your assessment of the patient, you note that his cardiac monitor shows atrial fibrillation at a rate of 160 beats/minute. A 68-year-old patient with a history of heart failure is receiving digoxin (Lanoxin). A patient with a history of chronic obstructive pulmonary disease is admitted to your floor with hypoxemia. An 86-year-old patient is found in his apartment without heat on a cold winter day. A patient admitted to the cardiac care unit with digoxin toxicity required transvenous pacemaker insertion. You immediately record a rhythm strip from his cardiac monitor and take his vital signs. A patient returns to your floor from the postanesthesia care unit after undergoing a right lower lobectomy. Which drug will the practitioner most likely prescribe to rapidly convert this rhythmfi You note the rhythm shown below when you record a rhythm strip from his cardiac monitor. A 36-year-old patient with a history of heart transplantation is admitted to your floor for observation after an appendectomy. To identify whether the patient is at risk for sudden death from sustained ventricular tachycardia C. He calls you into his room and complains of chest pain that he rates an 8 on a scale of 0 to 10 (10 being the worst). Which leads should you check to determine whether the block is in the right or left bundlefi After interpreting the rhythm strip shown below, what arrhythmia should you documentfi The bicuspid valve, commonly called the mitral valve is located between the left atrium and left ventricle. The circumflex artery supplies oxygenated blood to the lateral walls of the ventricle, the left atrium, and the left posterior fasciculus of the left bundle branch. Use a special rough patch on the back of the electrode, a dry washcloth, or a gauze pad to briskly rub each site until the skin reddens. It may also occur due to interference from other equipment in the room or improperly grounded equipment. Using the 8-step method of rhythm strip interpretation, you should check the rhythm first and then calculate the rate. If sinus arrhythmia develops suddenly in the patient taking digoxin, the patient may be experiencing digoxin toxicity. The patient with digoxin toxicity may develop arrhythmias, blurred vision, hypotension, increased severity of heart failure, yellow-green halos around visual images, anorexia, nausea, and vomiting. If the patient with atrial fibrillation complains of chest pain, emergency measures such as cardioversion are necessary. Digoxin may be used to control the ventricular response in patients with atrial fibrillation who are asymptomatic. You should instruct the patient to avoid tight clothing or direct pressure over the pulse generator, to avoid magnetic resonance imaging scans and certain other diagnostic studies, and to notify the practitioner if he feels confused, light-headed, or short of breath. The patient should also notify the practitioner if he has palpitations, hiccups, or a rapid or unusually slow heart rate.

Randomized insulin resistance parameters in patients with type 2 diabetrial of a multifaceted commercial weight loss program kan herbals discount hoodia 400 mg with mastercard. One-year treatment of obesity: a randomized herbs during pregnancy buy hoodia 400 mg cheap, doubleeffects of a commercially available weight loss program blind herbals laws purchase cheapest hoodia and hoodia, placebo-controlled herbals definition purchase online hoodia, multicentre study of orlistat herbs and rye hoodia 400 mg mastercard, a among obese patients with type 2 diabetes: a randomized gastrointestinal lipase inhibitor herbals and liver damage order hoodia cheap. Short-term medical benefts and adverse diet, on cardiovascular risk factors and insulin sensitivity effects of weight loss. Int year trial to assess the value of orlistat in the management J Obes Relat Metab Disord. Phentermine and long acting diethylpropion hydrochloride in obese patients topiramate for the management of obesity: a review. Safety and with ursodeoxycholic acid in patients participating in a effcacy of liraglutide in patients with type 2 diabetes and very-low-calorie diet program. Orlistat and acute prospective trial of prophylactic ursodiol for the prevenkidney injury: an analysis of 953 patients. Adler C, Schaffrath Rosario A, Diederichs C, ease undergoing hemodialysis, or hepatic impairment. Kidney stones, carbonic anhydrase inhibEuropean Society of Hypertension: obesity and diffcult to itors, and the ketogenic diet. Siebenhofer A, Jeitler K, Horvath K, Berghold A, an association that needs consideration. Sall D, Wang J, Rashkin M, Welch M, Droege C, effect of orlistat on body weight and cardiovascular disSchauer D. Gallstone foragonists on blood pressure, heart rate and hypertension mation prophylaxis after gastric restrictive procedures among patients with type 2 diabetes: a systematic review for weight loss: a randomized double-blind placebo-conand network meta-analysis. A comparative study of phentermine and and obese adults with elevated blood pressure. Ther Adv diethylpropion in the treatment of obese patients in general Cardiovasc Dis. Changes in cardiovascular risk assotion concealment] ciated with phentermine and topiramate extended-release 1512. A ranin participants with comorbidities and a body mass index domized, double-blind, placebo-controlled study of the fi27 kg/m(2). Cardiovascular effects of phentermine and topifor smoking cessation in patients hospitalized with acute ramate: a new drug combination for the treatment of obemyocardial infarction: a randomized, placebo-controlled sity. Glucagonmetabolic abnormalities in schizophrenia and related dislike peptide-1 receptor agonists and cardiovascular events: orders-a systematic review and meta-analysis. The cardiovascular effects of among those with mental disorders: a National Institute glucagon-like peptide-1 receptor agonists: a trial sequenof Mental Health meeting report. Cardiovascular of body mass index among individuals with and without safety of the glucagon-like peptide-1 receptor agonist schizophrenia. Lancet Diabetes Cardiometabolic risk factors in people with psychotic disEndocrinol. Obesity, serious mental illness and ysis of phase 2: 3 liraglutide clinical development studies. Alvarez-Jimenez M, Gonzalez-Blanch C, Crespolike peptide-1 receptor agonists for diabetes mellitus: a Facorro B, et al. Weight gain associated with reduced ejection fraction: design and rationale for the taking psychotropic medication: an integrative review. Suicide-related events in patients treated with antiantipsychotic drugs and obesity and diabetes. The descriptive epidemiology who have neuroleptic-induced weight or metabolic probof commonly occurring mental disorders in the United lems. The association between ioral weight-loss intervention in persons with serious menobesity and anxiety disorders in the population: a systemtal illness. A randomized controlled trial of a brief pathology in women: a three decade prospective study. Metformin for treatment of antipsychotic-induced loss in overweight and obese patients with schizophrenia weight gain: a randomized, placebo-controlled study. Lifestyle intervention and of antipsychotic-induced amenorrhea and weight gain in metformin for treatment of antipsychotic-induced weight women with frst-episode schizophrenia: a double-blind, gain: a randomized controlled trial. Effects of adjuncof a weight management program with food provision in tive metformin on metabolic traits in nondiabetic clozapschizophrenia. Bruins J, Jorg F, Bruggeman R, Slooff C, Corpeleijn weight gain during olanzapine treatment in patients with E, Pijnenborg M. Investigating the safety and effcacy of naltrexone for anti2014;40(6):1385-1403. Metformin for study protocol of a double-blind, randomized, placeboprevention of weight gain and insulin resistance with controlled trial. Metformin as zapineor olanzapine-treated patients with overweight or an adjunctive treatment to control body weight and metaobesity: a 16-week randomized, double-blind, placebobolic dysfunction during olanzapine administration: a mulcontrolled trial. Metformin addition ized placebo-controlled add-on study orlistat signifattenuates olanzapine-induced weight gain in drug-naive cantly reduced clozapine-induced constipation. Int Clin frst-episode schizophrenia patients: a double-blind, plaPsychopharmacol. Two forms of disordered eattients with schizophrenia and schizoaffective disorder. Extended lence and correlates of eating disorders in the National release metformin for metabolic control assistance durComorbidity Survey Replication. Zonisamide in the treatment of binge eating disorder with Psychological treatments of binge eating disorder. Night eating syndrome ing and weight loss outcomes in overweight and obese is associated with depression, low self-esteem, reduced individuals with type 2 diabetes: results from the Look daytime hunger, and less weight loss in obese outpatients. Binge status as syndrome; a pattern of food intake among certain obese a predictor of weight loss treatment outcome. Effect of Escitalopram for treatment of night eating syndrome: a orlistat in obese patients with binge eating disorder. Effcacy and therapy guided self-help and orlistat for the treatment of safety of lisdexamfetamine for treatment of adults with binge eating disorder: a randomized, double-blind, plamoderate to severe binge-eating disorder: a randomized cebo-controlled trial. Cochrane Database Imipramine and diet counseling with psychological supSyst Rev. Use of topiand the risk and prognosis of gallstone disease and pancreramate and risk of glaucoma: a case-control study. Android fat Topiramate use and the risk of glaucoma development: a distribution as predictor of severity in acute pancreatitis. Topiramate and the mass index and the risk and prognosis of acute pancreativision: a systematic review. Bupropion has Infammation, autophagy, and obesity: common features no effect on intraocular pressure or other ophthalmologic in the pathogenesis of pancreatitis and pancreatic cancer. Glucagonlike peptide 1-based therapies the prediction of severe acute pancreatitis. Obesity as a humans with increased exocrine pancreas dysplasia and risk factor for severe acute pancreatitis patients. Does the presence of obesity and/or metathe treatment of type 2 diabetes-more than meets the eyefi Dipeptidyl liraglutide in the treatment of obesity: a randomised, peptidase-4 inhibitors and pancreatitis risk: a meta-analdouble-blind, placebo-controlled study. Suazo-Barahona J, Carmona-Sanchez R, Robles-Diaz offspring: a systematic review and meta-analysis. Curr Opin Clin Nutr Metab exposure to liraglutide in a woman with Type 2 diabetes. Predictors of bone mass in perimenopausal drome reduces weight with improvement in lipid profle women. Epidemiology of vertebral fractures in like peptide 1 receptor agonist liraglutide leads to signifwomen. Epidemiology of sarcopenia among the elderly in New Weight change and fractures in older women. Attenuation mortality in older men and women with and without diaof skeletal muscle and strength in the elderly: the Health betes mellitus: the Rancho Bernardo study. Prevalence, pathophysiology, health consequences and Prospective study of intentionality of weight loss and mortreatment options of obesity in the elderly: a guideline. Quebbemann B, Engstrom D, Siegfried T, Garner K, cal frailty in very elderly people. Effect of weight loss with reduction of ral impulse control mechanisms for dietary success in obeintra-abdominal fat on lipid metabolism in older men. The role of ghrelin in drug and natural cise, improves pulmonary function in older obese men. Recent advances in the development of Prescription of topiramate to treat alcohol use disorders treatments for alcohol and cocaine dependence: focus on in the Veterans Health Administration. Neural a cross sectional study: importance of picking or nibbling and behavioral effects of a novel mu opioid receptor on weight regain. Treatment of diabetes after gastric bypass in patients with midto longbulimia with bupropion: a multicenter controlled trial. Oral topireview of defnitions of failure in revisional bariatric surramate for treatment of alcohol dependence: a randomised gery. If the complications have not been ameliorated, weight-loss therapy should be intensifed or Follow-Up complication-specifc interventions need to be employed. Therefore, patients require ongoing follow-up, re-evaluation and long-term treatment. Obstructive Sleep Apnea Physical exam; neck circumference; Polysomnography needed to complete diagnosis. Bioelectric impedance, adiposity air/water displacement plethysmography, or dual-energy absorptiometry scan may be considered. Iatrogenic Obesity Review current medications and Withdraw ofending medication and/or substitute with weight-neutral alternative. Patients with overweight or obesity who Add medication for patients who have have no clinically signifcant weight-related progressive weight gain or who have not complications (secondary prevention) achieved clinical improvement in weight-related complications on lifestyle therapy alone. These patients should be followed over time and evaluated for changes in both anthropometric and clinical diagnostic components. The diagnoses of overweight/obesity stage 0, obesity stage 1, and obesity stage 2 are not static, and disease progression may warrant more aggressive weight-loss therapy in the future. Stages are determined using criteria specifc to each obesity-related complication; stage 0 = no complication; stage 1 = mild to moderate; stage 2 = severe. Treatment plans should be individualized; suggested interventions are appropriate for obtaining the sufcient degree of weight loss generally required to treat the obesity-related complication(s) at the specifed stage of severity. The conceptualization of obesity as a lifestyle choice and primarily a cosmetic concern is not only debunked by scientifc evidence, but has failed our patients and our societies. This shift can only be achieved through activated health care systems, as well as regulatory and legislative measures that ensure patient access to therapies of proven beneft. The guidelines target more aggressive treatment for patients with weight-related complications who beneft most from weight loss and as such, optimize beneft/ risk ratios and cost-effectiveness. The core aspiration is that patients become activated and empowered, while health care systems become prepared and proactive. The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model. Non-motor symptoms include depression, sleep problems, anxiety, excessive sweating, constipation and pain.

Most of these lifestyle intervention studies diet or a control intervention demonstrated that weight loss resulted in <5% weight loss (mean 4 herbs de provence walmart purchase hoodia 400 mg fast delivery. Liraglutide walking herbalshopcompanynet purchase genuine hoodia on line, weight machine resistance 18 herbals order hoodia 400 mg online, and combination of 3 mg resulted in 4 kairali herbals generic hoodia 400mg visa. During this time herbals on york carlisle pa best 400 mg hoodia, hypertentution over an 18-year period (mean age 42; 69% women; sion occurred in 11 control subjects (25 herbals images 400 mg hoodia fast delivery. Does weight loss prevent cardiovasassociated with a lower remission rate 1 year after surgery cular disease events or mortalityfi Does weight loss improve congesretrospective analysis, N = 43,457]) who answered questive heart failure and prevent cardiovascular tionnaires describing weight-loss efforts in 1959-1960. They found that intentional weight loss was associated sons: (1) the confounding effect of concurrent therapy spewith a 25% reduction in total mortality and a 28% reduccifcally targeted to risk factors can affect mortality. However, there are post-hoc analyses not demonstrate signifcant reductions in mortality when of data from prospective studies and retrospective cohort compared with the control group. Current reductions in mortality in patients undergoing bariatric surguidelines for the management of heart failure provide gery. In addition, there were no signifcant effects (n = 33); these groups attained weight loss of 8. Weight loss ing insulin, and fasting glucose; there were no statistically was comparable in both groups, amounting to 12. The women were monitored on average 3 times daily, n = 40) or metformin (500 mg 3 times daily, for 20. Ovulation rate was 15% in the levels, or menstrual cycle regularity/restoration; (2) the orlistat-treated group and 30% in the metformin-treated partial responder group, comprising 47. Regarding medicine-assisted weight and improved lipid and hormonal measures, induced ovuloss, clinical trial data are available for orlistat (1006 lation, and restored menstrual cycles. While liraglutide at 3 mg/day has been approved iopancreatic diversion or by laparoscopic gastric bypass, for weight loss, the effcacy of lower doses (0. This open-label study included 40 women of the women by 8 months and an additional 25% had who were then randomized to 1 of 3 arms: (1) 1,000 mg moderate resolution of their hirsutism at 21 months (1010 of metformin twice daily, (2) 1. All 6 patients who desired pregnancy Multiple clinical trials and meta-analyses, includfollowing surgery conceived within 3 years of surgery. How much ysis assessing treatment with metformin demonstrated an weight loss would be requiredfi Metformin therapy has been consiswomen with overweight and obesity and should tently shown to result in modest weight loss; it is not clear be considered as part of the initial treatment to the degree to which weight loss versus other actions of the improve fertility; weight loss of fi10% should be drug are responsible for the therapeutic effects. A lifestyle intervention trol studies, cohort studies, or case series involving small program including 58 women with obesity and menstural numbers of patients. Additionally, women with >10% maternal complications for women who had undergone weight loss were more likely to have live births (71% vs. Thus, a 10% reduction in body weight appears to result in Additional cohort studies (and case reports) have also increased rates of pregnancy, albeit larger prospective trials examined whether weight-loss interventions improve outare required to confrm these fndings. None of the men the position of the Practice Committee of the received testosterone therapy. The prevalence and hypogonadism, long-term testosterone therapy in 411 of metabolic syndrome declined from 87% of subjects at men (mean age 58. Long-term metato be effective for sustained weight loss, irrespective of bolic effects were associated with lower concentrations their baseline weight. Is weight loss effective to treat obstrucin 158 patients with diabetes was associated with a 4. How much weight loss would be weight loss over 3 months, together with signifcant reducrequiredfi Is weight loss effective to treat asthma/reacage number of apneic/hypopneic episodes per hour during tive airway diseasefi The subgroups were compared for naturally results indicated that for each unit of weight loss there was occurring changes in body weight. Importantly, ing pain, in knees and ankles of men and women with odds when weight-loss categories of >10%, 5 to 9. For tive patients followed prospectively after bariatric surgery, these reasons, weight loss is recommended both before there was a signifcant increase in medial joint space on and after knee replacement surgery in patients with overknee X-rays and clear improvements in the Knee Society weight and obesity. How much weight loss would be knee physical function, and knee stiffness showed a signifrequiredfi Two prospective cohort studies demonstrated had decreased from 8% at baseline to 5. A systematic review identifed the benefts were largely confned to those women losing 5 interventional cohort studies involving bariatric surgery, >5% body weight. All patients who have overweight or obethe intensive group reported urinary incontinence (25. Intragastric balloon for weight loss may increase exercise, and behavior modifcation) or to a structured edugastroesophageal refux symptoms and should not cation control program. After 6 months, the intervention be used for weight loss in patients with established group achieved a mean weight loss of 8. A total of 15% and 65% of subjects tionnaire scoring and having symptoms for at least 6 had partial and complete resolution of refux symptoms, months were recruited to assess the effect of weight loss respectively. There was a signifcant ment in a randomized double-blind study of 17 young association between a high-calorie and high-fat diet and patients with marked obesity (166. Only marked weight loss appeared to or a weight-loss diet (600 calories below daily estimated have an effect on refux in this short study. Patients with Baseline 24-hour pH monitoring identifed refux in 52% of concurrent irritable bowel symptoms had a signifcantly subjects, pathologic total time of gastroesophageal refux poorer response, whereas age, H. At 4 months, sham treathigher gastric pH (percent time >pH 3 and 4) and a lower ment resulted in 9. Esophageal acid exposure and gastric pouch acid(n = 34) were found to have hiatal hernia intra-operatively. Some pre-operative severity of heartburn and regurgitation comstudies suggest exacerbation of depression by obesity while pared to the redo fundoplication group. Three-year followothers suggest attenuation of depressive symptomatolup data was available for 132 of the 183 patients (n = 89 ogy. Participants taking antidepressant medications gies versus a control (no-treatment) group. At baseline, 25% of stability for African American women in North Carolina the patients (n = 211) were deemed to have depression and (Shape Program, Duke) included 185 women (average were on antidepressant medications. Study results vary from 1 large trial demonstrating loss is required to achieve an improvement in symptoms that an ~8% decrease in body weight results in attenuation of depression or whether the intervention itself may prove of depressive symptomatology to smaller studies suggestto be helpful in mitigating or attenuating depressive symping that it may be the intervention itself (without any preditoms in individuals with overweight or obesity. Future studies may ther studies are needed to elucidate whether a clear relaseek to quantify this relationship. Even though the macronutrient composition One meal plan that can be effective in patients with of meals has less impact on weight loss than adhercardiometabolic risk is represented by Mediterranean diets ence rates in most patients, in certain patient poputhat are characterized by a reliance on olive oil, which conlations, modifying macronutrient compositions tains the monounsaturated fat oleic acid as ~75% of fatty may be considered to optimize adherence, eating acids, as a fat source. Mediterranean diets have been shown to have favorable clinical effects Evidence Base in patients with cardiometabolic risk and insulin resisDietary or eating patterns represent the totality of a tance, including long-term outcome studies demonstrathuman diet over the course of a specifed time period. For many commercial diets with variable macronutriIn sum, the prime determinant of weight loss is energy ent percentages, micronutrient defciencies are more likely. However, there are proven and higher protein was found to have the most favorable benefts of certain eating patterns with varying macronumicronutrient content, compared with lower carbohydrate, trient distributions in select patient groups. Lower fat intake can reduce energy density and prescribed to patients with overweight or obesity the potential for caloric overconsumption, with as as a component of lifestyle intervention; the initial yet unproven harm; and prescription may require a progressive increase in 3. The prescription for physical activity should women, structured exercise activities were shown to be be individualized to include activities and exercise associated with clinically relevant additional weight loss of regimens within the capabilities and preferences of >2. A meta-analysis of pedometer activity/week) are needed to attenuate weight gain (1307 interventions showed a modest weight loss of 1. The general goal should be resistance training vigorous aerobic exercise spread out during at least 3 days 2 to 3 times per week consisting of single-set exercises that during the week, with no more than 2 consecutive days use the major muscle groups with a load that permits 10 between bouts of aerobic activity. Many of the large successful trials showing improved A systematic review of pedometer studies along with fat loss with physical activity (cited above) utilized the a meta-analysis of pedometer-based walking programs, participation of exercise physiologists and other ftness both including randomized trials and observational studies, professionals. The behavior intervention package is effecof the patient to allow for the optimal amount of conditively executed by a multidisciplinary team that tioning. Lifestyle therapy should include increased physiincludes dietitians, nurses, educators, physical cal activity even though the patient is unable to engage in activity trainers or coaches, and clinical psyoptimal physical activity. Behavioral lifestyle intervention and supprovider and the patient should together establish the exerport should be intensifed if patients do not cise prescription with the goal of long-term compliance. Another study compared the effectivePotential venues for the interventions include the clinic ness of 3 behavioral interventions that varied in intensity offce, community facilities, and commercial entities. Psychologists strategies combined with patient exercise and nutrition, and psychiatrists will need to participate in the treatment a semistructured approach with basic counseling, or of eating disorders, depression, anxiety, psychoses, and unstructured advice. At the end of the 17to 20-month other psychological problems that impair the effectiveness intervention period, the highly structured behavior of lifestyle intervention programs unless addressed in a prigroup showed an average weight loss of 5. Studies were included in this review if they primary care providers for approximately 14 brief (10to reported intervention effects on behavioral mediators. Mediators associated had to include at least 15 participants with an attrition with a longer duration of weight control included higher rate of <30% at 1 year. Inclusion criteria modifcation to assist participants in achieving the study for these studies required interventions to be widely availweight-loss goals. The behavior lifestyle program was able and presented by the therapists who would deliver presented to patients by case managers on a one-to-one the intervention in routine practice. Only 8 trials met the basis during the frst 24 weeks and was fexible, culturinclusion criteria. Subsequent individual from 5 studies of commercial weight management prosessions usually occurred monthly, and group sessions grams detected signifcant weight loss at 1 year. Two studwith case managers were provided to reinforce behavioral ies of a commercial program with meal replacements also changes. Patients who met addition, a greater weight loss achieved at 6 months was the initial 6-month study goals were 1. The percent weight loss at week identifed, nonresponders could be offered a more inten5 was signifcantly associated with greater weight loss at sive, stepped-care intervention, based upon studies that both 4 and 7 months. Twenty-two studies with 4,659 Other studies have found that early weight loss during patients included follow-ups ranging from 1 to 5 years. There were considerable differences in the blinded primary study, secondary subset analysis]; 1385 care provided to the comparison groups. One-third and behavioral intervention, those who had greater calorie of patients lost >5% body weight after 12 months, and inirestriction with a very low-calorie diet lost 3. For those who received identical dietary and behavWeight reduction early in a weight-loss program is ioral interventions, patients with more intense physical a key predictor of long-term weight-loss success even in activity lost 3. A total of 19 study groups were A group-based behavioral intervention study randomly generated from 8 trials that compared 2 weight-loss interassigned 692 women to receive supplemental telephone ventions and 3 trials that compared weight-loss intervencounseling and tailored newsletters or a less-intensive tion with usual care/controls. In studevery other week for another 2 months, and then monthly ies that observed <5% weight loss, the average changes for the remainder of the year. The Mediterranean-style diet was rich in vegetareminders, and support for lifestyle behavior change, but bles, whole grains, and olive oil, and patients had their the program was not interactive. After 6 used meal replacements or a structured food plan as well as months, the intervention group had signifcant benefcial one-on-one and group counseling sessions. A weight loss of >5% appears necessary for benefsupport in achieving weight loss. Subjects that completed mobile app was used to supplement in-person educational the study decreased their uncontrolled eating score and sessions and included electronic diaries for self-monitorincreased their cognitive restrained eating. Interactive their emotional eating, but no signifcant change was seen content included daily messages, video clips, and quizzes in women. The control group received was signifcantly and positively associated with weight educational material about prediabetes, was given a display loss in both men and women that completed the study. There was that fi87% of these participants maintained a weight loss of no signifcant effect on fasting glucose or lipid levels. A 2015 systematic review and meta-analysis of 12 Structured Lifestyle Intervention Programs. The and behavior interventions with a standard or usual care respective retention rates for the intervention and control control subgroup. Lifestyle therapy programs produced groups were 66% versus 94% at 6 months and 53% versus substantially greater weight loss in multiple such studies 88% at 12 months. The Web-based weight-loss style therapy programs should be available to patients who program included information on healthy lifestyle, weekly are being treated for the disease of obesity. Thus, the drugs alone resulted in in face-to-face meetings and group sessions and/or using only modest weight loss with inferior outcomes compared remote technologies (telephone, Internet, text messaging). Is pharmacotherapy effective to treat overweight the effects of drug therapy alone in the absence of lifeand obesityfi

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