Obesity is more strongly related to morbidity and disability than to mortality. Following a representative cohort of 19 518 Finnish adults for 15 years, Visscher and colleagues showed that obesity has a lifetime impact on disability and morbidity. Obese men and women had an increased number of unhealthy life-years owing to work disability, coronary heart disease, and premature need for long-term medication compared with normal-weight counterparts. A further increase in obesity will lead to an increase in unhealthy life-years and in direct and indirect health care costs.
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An evidence-based practice guideline produced by the American Society of Addiction Medicine found that sedative hypnotic medications were more effective than neuroleptics in reducing duration of delirium and mortality in alcohol withdrawal delirium. There were no deaths reported in 217 patients from randomized trials using benzodiazepines or barbiturates, with no differences found among various agents in these classes. Key recommendations are that treatment should focus on rapid control of agitation using parenteral rapid-acting hypnotics that are cross-tolerant with alcohol, followed up with adequate dosages to maintain light somnolence for duration of the delirium. Coupled with comprehensive supportive care, this approach is highly effective in preventing morbidity and mortality.
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Weight loss is a key facet of clinical care for persons with diabetes mellitus, but is difficult to achieve and maintain in the long term. Norris et al present a systematic review of randomized controlled trials of pharmacotherapy for weight loss in adults with type 2 diabetes mellitus. Sufficient data for a meta-analysis were available for fluoxetine, orlistat, and sibutramine, and these drugs can achieve modest but statistically significant weight loss over 26 to 52 weeks (2.6-5.8 kg; 2%-3% of initial body weight). However, longer-term benefits and safety remain unclear.
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Renal transplantation is the treatment of choice for most patients with end-stage renal disease, the incidence and prevalence of which is increasing in many developed countries. Despite a large increase in kidney donation by living donors over the last 10 years, a shortage of transplantable organs remains a major problem. Fortunately, over the same period, rates of acute rejection have fallen, and transplanted kidneys are surviving longer. In this article, Magee and Pascual discuss strategies to reduce the organ shortage and review the advances in immunosuppression, which have contributed to better kidney transplant survival. As early posttransplant outcomes are now so good, there is more emphasis on the prevention and treatment of long-term complications of transplantation such as cardiovascular disease, neoplasia, and bone disease. A multidisciplinary approach is thus needed to optimize long-term outcomes in renal transplant recipients.
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Moderate doses of statins decrease mortality, coronary heart disease (CHD) or cerebrovascular events, and cardiovascular procedures in adults with CHD by 16% to 24%. The benefits occur within 2 years of initiation of statins, at pretreatment low-density lipoprotein cholesterol (LDL-C) levels less than 100 mg/dL (<2.59 mmol/L), in women and the elderly, and are independent of concomitant CHD medications. The preferred dose of statins is not known, though most trials used moderate fixed doses. There is no conclusive evidence that lowering LDL-C level to less than 100 mg/dL (<2.59 mmol/L) with statin therapy is superior to lowering to between 100 and 130 mg/dL (2.59-3.36 mmol/L). However, the results from 2 other meta-analyses suggest that risk reduction is related to the reduction in cholesterol levels.
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In This Issue of Archives of Internal Medicine. Arch Intern Med. 2004;164(13):1361. doi:10.1001/archinte.164.13.1361