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By B. Nemrok. LeTourneau University. 2018.

Referral for bariatric surgery Key Concept/Objective: To understand how BMI determines treatment of obese patients The approach to the treatment of obesity is similar to that of other chronic conditions 15 mcg mircette, such as hypertension purchase 15 mcg mircette mastercard, hypercholesterolemia, and diabetes. Patients are first managed with lifestyle measures for 3 to 6 months. For obesity, these lifestyle interventions include improved diet and increased activity. For patients whose weight does not change with lifestyle intervention alone or whose weight loss is insufficient to lower their long-term health risk, consideration is then given to pharmacologic or surgical management. A National Institutes of Health expert panel has suggested that patients whose BMI is 30 kg/m2 or more or who have a BMI of 27 kg/m2 or more plus obesity-related risk factors (i. Patients with a BMI of 40 kg/m2 or more or a BMI of 35 kg/m2 or more plus obe- sity-related risk factors could be considered for surgical therapy. In this patient, the com- bination of hypertension, glucose intolerance, osteoarthritis, and a BMI greater than 35 kg/m2 warrants referral for bariatric surgery. A 46-year-old African-American man presents to your office for a routine visit. On his last visit, which was 18 months ago, he was noted to be mildly hypertensive and obese. He underwent blood test screen- ing for high lipid levels, thyroid disease, and glucose intolerance; all results were normal. He reports that he frequently falls asleep during the day, occasionally when driving a car. The patient should be asked about his sleeping habits and referred for a sleep study Key Concept/Objective: To understand that sleep apnea is a common complication of obesity In epidemiologic studies, persons who are overweight or obese and have central adiposity are at increased risk for hyperlipidemia, hypertension, and cardiovascular disease mortal- 3 ENDOCRINOLOGY 17 ity. Sleep apnea is likely underdiagnosed in overweight and obese patients and should be strongly considered in patients with complaints of fatigue, daytime somnolence, snoring, restless sleep, and morning headaches. Although fatigue can be attributed to primary cardiac or pulmonary disease, neither would explain the daytime somnolence and the morning headaches. A 35-year-old white woman comes to your office requesting your opinion on how to lose weight. She has no known complications or associated comorbidities secondary to obesity. She read on the Internet that approaches to weight loss are based on the calculation of BMI. She tells you that because her BMI is 33 kg/m2, medical therapy is indicated. Her sister has had great success taking orlistat, having lost 20 lb without having any significant side effects. Which of the following statements regarding the use of orlistat therapy in this patient is true? Orlistat is generally safe and well tolerated by most patients; the patient should be started on orlistat therapy in conjunction with a diet-and-exercise program B. The patient should be started on orlistat therapy; there is no need to prescribe C. Orlistat is generally safe, but a significant number of patients experi- ence side effects; the patient should be started on orlistat therapy in conjunction with a diet-and-exercise program D. Orlistat is poorly tolerated by most patients and has life-threatening side effects Key Concept/Objective: To know the side effects of orlistat Diet and exercise are the cornerstones of any weight loss program. Medication, including orlistat, should be considered as an adjunct to diet and exercise. Orlistat inhibits lipases in the gastrointestinal lumen, thereby antagonizing triglyceride hydrolysis and reducing fat absorption by roughly 30%. Gastrointestinal side effects may occur in up to 80% of patients when they begin therapy with orlistat (such side effects are also seen in 50% to 60% of patients given placebo), but this incidence diminishes with time. Symptoms include abdominal discomfort, flatus, fecal urgency, oily spotting, and fecal incontinence. When administered to patients who adhere to a low-fat diet, orlistat is generally well tol- erated. Other than the gastrointestinal symptoms, orlistat is well tolerated without any other significant side effects. Nevertheless, orlistat should not be given to patients with existing malab- sorptive states, and it is recommended that a daily multivitamin supplement be taken by patients during therapy. A 55-year-old man with long-standing gastroesophageal reflux disease (GERD) is found to have Barrett esophagus on a routine upper GI endoscopy. He takes proton pump inhibitor (PPI) therapy every day, and he reports that his heartburn is under reasonable control. What would you recommend regarding the treatment of this patient’s Barrett esophagus? Start an endoscopic surveillance program to look for dysplastic lesions B. Increase the PPI dose to maximally suppress acid secretion C. Refer for antireflux surgery to decrease the chances of progression to esophageal adenocarcinoma D. Refer for esophagectomy Key Concept/Objective: To understand the treatment of Barrett esophagus Barrett esophagus is a sequela of chronic GERD in which the stratified squamous epitheli- um that normally lines the distal esophagus is replaced by abnormal columnar epitheli- um.

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In: Vinken PJ buy mircette 15mcg low cost, Bruyn GW (eds) Handbook of clinical neurology discount mircette 15mcg. American Elsevier, New York, pp 303–310 Busis NA (1999) Femoral and obturator neuropathies. Neurol Clin 17: 633–653 Kim DH, Kline DG (1995) Surgical outcome for intra- and extrapelvic femoral nerve lesions. J Neurosurg 83: 783–790 Kuntzer T, Van Melle G, Regli F (1997) Clinical and prognostic features of femoral neuropathies. Muscle Nerve 20: 205–211 Mark MD, Kwasnik EM, Wright SC (1990) Combined femoral neuropathy and psoas sign: an unusual presentation of iliac artery aneurysm. Am J Med 88: 435–436 Simmons Z, Mahadeen ZI, Kothari MJ, et al (1999) Localized hypertrophic neuropathy; magnetic resonance imaging findings and long term follow up. Muscle Nerve 22: 28–36 217 Saphenous nerve Genetic testing NCV/EMG Laboratory Imaging Biopsy + The saphenous nerve is one of three sensory branches of the femoral nerve. Anatomy (The others being the medial and intermediate femoral cutaneous nerves. Numbness, but also severe neuropathic pain may occur. Signs Entrapment at Hunter’s canal causes pain in the lower thigh and leg. Diagnosis Anatomical sites is made by application of local anesthetics. Infrapatellar branch: Lesion of the infrapatellar branch may cause a small sensory loss below the knee. Entrapment above the medial ankle (nerve anterior to the prominence of medial malleolus) causes saphenous neuritic pain. Arthroscopy Causes Bursitis of pes anserinus Compression in the subsartorial canal Hunter’s canal operations, vascular disease, venous stripping Gonyalgia paresthetica Knee surgery (infrapatellar branch): meniscectomy Neurolemmoma Neuropathia patellae: distal terminal branch of infrapatellar ramus. Phlebitis of the saphenous vein Postures: straddling surfboard, playing “viola da gamba” Surgery: arterial reconstruction, venous grafting, varicose vein operations Transplantation: this nerve is often used for nerve transplantation Sensory NCV Diagnosis EMG (for differentiation from L4) L4, partial femoral neuropathy Differential diagnosis 218 References Dawson DM, Hallet M, Wilbourn AJ (1999) Entrapment neuropathies of the foot and ankle. In: Dawson DM, Hallet M, Wilbourn AJ (eds) Entrapment neuropathies. Lippincott-Raven, Philadelphia, pp 297–334 Mumenthaler M, Schliack H, Stöhr M (1998) Isolierte N. In: Mumen- thaler M, Schliack H, Stöhr M (eds) Läsionen peripherer Nerven und radikuläre Syndrome. Thieme, Stuttgart, pp 393–464 Staal A, van Gijn J, Spaans F (1999) The femoral nerve. In: Staal A, van Gijn J, Spaans F (eds) Mononeuropathies. Saunders, London, pp 103–108 Stewart JD (2000) Femoral and saphenous nerve. Lippincott, Philadelphia, pp 457–473 219 Cutaneous femoris lateral nerve Genetic testing NCV/EMG Laboratory Imaging Biopsy + – Fig. Iatrogenic lesion of the lateral cutaneous femoris nerve. Several scars near anterior su- perior iliac spine Sensory nerve, with fibers from L2 and L3. Exits the pelvis medial to the anterior Anatomy superior iliac spine. It is enclosed between two folds of the lateral attachment of the inguinal ligament, with various paths to exit the pelvis. The nerve changes course from a horizontal to a vertical position. Pain, tingling or burning, or numbness of the anterolateral and the lateral Symptoms aspects of the thigh. Sometimes highly irritable (can be irritated by clothes). Standing or walking can also aggravate, whereas hip flexion provides relief. Deficits of superficial sensory sensation in the center of the lateral cutaneous Signs nerve’s distribution, known as meralgia paresthetica. May be precipitated by hip extension, or pressure on an entrapment point (Tinel’s sign). Muscle Nerve 22: 1129–1131 Staal A, van Gijn J, Spaans F (1999) The lateral cutaneous nerve of the thigh. WB Saunders, London, pp 97–100 van Eerten PV, Polder TW, Broere CA (1995) Operative treatment of meralgia paresthetica: transsection versus neurolysis. Neurosurgery 37: 63–65 Williams PH, Trzil KP (1991) Management of meralgia paresthetica. J Neurosurg 74: 76–80 221 Cutaneous femoris posterior nerve Genetic testing NCV/EMG Laboratory Imaging Biopsy + Fibers come from the lower part of the lumbosacral plexus, roots S1–3. The Anatomy fibers descend together with the inferior gluteal nerve through the greater sciatic notch, below the piriformis muscle. The sensory area includes the lower buttock, parts of the labia or scrotum, dorsal side of the thigh and proximal third of the calf. The autonomic field is a small area above the popliteal fossa.

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Macrocomedones are also a They need to be treated for two reasons buy mircette 15mcg visa. They are a cos- cause of a slow and poor response to oral isotretinoin ther- metic problem and may flare into inflamed lesions (fig order mircette 15 mcg fast delivery. In such patients, they are the major reason for a severe flare Drug-Induced Comedones of the acne and surprisingly are easily missed unless ade- These may be due to corticosteroids [29, 30] or ana- quate lighting and examination techniques, i. The optimum therapy is gentle cautery albeit very infrequently, due to minocycline-induced pig- [26–28]. This is performed under topical local anaesthesia mentation. Treatment of drug-induced comedones is by using an anaesthetic cream such as EMLA® which is removal of the cause and by treating with either topical applied for 60–75 min under an occlusive dressing such as retinoids or gentle cautery. The area is then lightly touched with a small hot-wire cautery probe, the tip being grey in colour rather Pomade Comedones than vividly red and red-hot. The purpose is not to burn This is a clinical event seen particularly in Afro-Carib- the skin significantly but to produce low-grade, localised beans who apply hair preparations to defrizz their hair. This therapy is far superior to topical Many whiteheads (fig. Treatment in- 14 Dermatology 2003;206:11–16 Cunliffe/Holland/Clark/Stables cludes stopping the hair preparations, topical retinoids and possibly oral antibiotics. Chloracne This is also characterised by many comedones [33–36]. Indeed, comedonal acne is a hallmark of this disease (fig. In- flamed lesions may be treated with oral or topical benzoyl peroxide or antibiotics. Gentle cautery is very successful; there is usually a poor response to topical and oral reti- noids. Naevoid Comedones 6 These are rare and may present before puberty but more often at and around puberty [37, 38]. The lesions may be typical confluent comedones (fig. They may be localised or, in some unfortunate individuals, extremely extensive. Response to oral and topical retinoids is unsatisfactory. Physical methods are also unsatisfactory, but gentle cautery, excision of locally affected areas and carbon dioxide laser therapy can be tried; however, as yet there seems to be no satisfactory solution for the majority of patients. Conglobate Comedones Patients with conglobate comedones are predominant- ly males with extensive truncal acne characterised by severe nodular inflammation and scarring. A hallmark of the disease is grouped comedones [40, 41], particularly on the posterior neck and upper trunk. The comedones may be blackheads, whiteheads or both. There are no satisfactory data to 7 demonstrate which is the preferred way of treating such comedones. New Topical Retinoids New topical anti-acne therapies are required for sever- al reasons. There is no topical anti-acne therapy which reduces lesions by over 60% in contrast to, for example, oral isotretinoin which can suppress lesions by 100%. This may simply be a measure of penetration of the drug. Most topical therapies frequently produce an irritant der- matitis, and this will reduce compliance. Many antibiotics have been shown to produce resistant P. Comedogenesis: Aetiological, Clinical and Dermatology 2003;206:11–16 15 Therapeutic Strategies using new vehicle delivery systems [42, 43]. It is not the Acknowledgements intention of this review to discuss the pros and cons of This study was financially supported in part by the Leeds Foun- such therapies, except to say that some newer drugs and dation for Dermatological Research, Roche, Galderma and Dermik. With the permission of the British Journal of Dermatology to re-publish this paper in a shorter version. References 1 Cunliffe WJ, Simpson NB: Disorders of the 16 Chalker DK, Lesher JL, Smith JG, et al: Effica- 30 Monk B, Cunliffe WJ, Layton AM, Rhodes DJ: sebaceous gland; in Champion RH, Burton JL, cy of topical isotretinoin 0. Clin Burns DA, Breathnach SM (eds): Textbook of garis: Results of a multicenter, double-blind Exp Dermatol 1993;18:148–150. J Am Acad Dermatol 1987;17: 31 White Gl Jr, Tyler LS: Blackmarket steroids 1998, pp 1927–1984. J Fam Pract 2 Burton JL, Shuster S: The relationship between 17 Shalita A, Weiss JS, Chalker DK, et al: A com- 1987;25:214. Br J Dermatol parison of the efficacy and safety of adapalene 32 Fyrand O, Fiskdaadal HJ, Trygstad O: Acne in 1971:84:600–601. Acta Derm Venereol (Stockh) 1992; pionibacterium levels in patients with and Acad Dermatol 1996;34:482–485. J Invest Dermatol 1975; 18 Kligman AM: The treatment of acne with topi- 33 Crow KD: Chloracne and its potential clinical 65:382–384. Clin Exp Dermatol 1981;6:243– 4 Webster GF: Inflammation in acne vulgaris. Br J Der- 20 Sanders DA, Philpott MP, Nicolle FV, Kealey Dermatol 1996;35:643–645. T: The isolatioin and maintenance of the hu- 35 McConnell R, Anderson K, Russell W, et al: 6 Plewig G, Fulton JE, Kligman AM: Cellular man pilosebaceous unit. Br J Dermatol 1994; Angiosarcoma, porphyria cutanea tarda and dynamics of comedo formation in acne vulga- 131:166–176.

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J Bone Joint Surg[ Am] 1999 buy generic mircette 15 mcg on line; knee pain after anterior cruciate ligament reconstruc- 81: 549–557 discount 15 mcg mircette visa. Anterior cruciate ligament reconstruction anterior cruciate ligament ruptures: Intermediate using one-third of the patellar ligament, augmented by results. Jackson, DW, ES Grood, JD Goldstein, MA Rosen, PR 1982; 64: 352–359. Reconstruction of the anterior cruciate lig- of patellar tendon autograft and allograft used for ante- ament. Reconstruction of the anterior cruciate Am J Sports Med 1993; 21: 176–185. Reconstruction of the anterior cruciate the anterior cruciate ligament with human allograft: ligament using the central one-third of the patellar lig- Comparison of early and later results. Marshall, JL, RF Warren, TL Wickiewicz, and B Reider. Iliotibial band transfer The anterior cruciate ligament: A technique of repair through the intercondylar notch for combined anterior and reconstruction. Reconstruction of the anterior cruciate lig- tendon-patellar bone autograft. J Trauma 1999; 46: ament in athletes, using a fascia lata graft: A review with 678–682. Results of reconstruction of acute ruptures of the ante- 35. Outcome rior cruciate ligament with an iliotibial band auto- of anterior cruciate ligament reconstruction using graft. Knee Surg Sports Traumatol Arthrosc 1999; 7: quadriceps tendon autograft. Reconstruction of the anterior cruciate intra-articular iliotibial band augmentation in the treat- ligament with quadriceps tendon. Arthroscopy 2002; 18: ment of an acute anterior cruciate ligament rupture: E37. Donor-Site Morbidity after Anterior Cruciate Ligament Reconstruction Using Autografts 317 37. Sports Med 1995; 19: of the human knee and its functional importance. Harner, CD, JJ Irrgang, J Paul, S Dearwater, and FH Fu. Loss of motion after anterior cruciate ligament recon- Berlin: Springer-Verlag, 1972. Kartus, J, L Magnusson, S Stener, S Brandsson, BI angle for harvesting autogenous tendons for anterior Eriksson, and J Karlsson. Surg Radiol Anat arthroscopic anterior cruciate ligament reconstruction: 2004; 26: 167–171. A 2- to 5-year follow-up of 604 patients with special 56. Johnson, RJ, DB Kettelkamp, W Clark, and P Leaverton. Knee Surg Sports Factors effecting late results after meniscectomy. The incidence of prepatellar neuropathy ment reconstructions with patellar tendon grafts. Clin Orthop 1983; 181: Med Arthrosc Rev 1997; 5: 156–162. Late results after menis- Patellofemoral problems after intraarticular anterior cectomy. The ramus infrapatellaris score, and the Cincinnati knee score: A prospective of the saphenous nerve and its importance for medial study of 120 ACL reconstructed patients with a 2-year parapatellar arthrotomies of the knee. Knee Surg Sports Traumatol Arthrosc 1999; 7: Traumatol 1978; 16: 95–100. Muneta, T, I Sekiya, T Ogiuchi, K Yagishita, H branch of saphenous nerve in arthroscopic knee sur- Yamamoto, and K Shinomiya. Scand J Med Sci sympathetic dystrophy of the knee after sensory nerve Sports 1998; 8: 283–289. Knee strength deficits after hamstring ten- Joint Surg [Br] 1952; 34: 41–44. Med Sci Sports Exerc 2000; 32: ing from dashboard injury. Entrapment neuropathy of of patellar tendon and hamstring tendon anterior cruci- the infrapatellar branch of the saphenous nerve. Am J Sports Med 2003; 31: Sports Med 1977; 5: 217–224. Adachi, N, M Ochi, Y Uchio, Y Sakai, M Kuriwaka, and Duane. Saphenous nerve entrapment: A cause of medial A Fujihara. Arch Orthop Trauma Surg 2003; tion: A surgical procedure for control of rotatory 123: 460–465. Tashiro, T, H Kurosawa, A Kawakami, A Hikita, and 226–242. A lateral skin incision reduces on knee flexor strength after anterior cruciate ligament peripatellar dysaesthesia after knee surgery.

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