George P. N. Samraj

Nonsteroidal anti-inflammatory drugs in the treatment of low back pain

Low back pain (LBP) is amongst the top ten most common conditions presenting to primary care clinicians in the ambulatory setting. Further, it accounts for a significant amount of health care expenditure; indeed, over one third of all disability dollars spent in the United States is attributable to low back pain. In most cases, acute low back pain is a self-limiting disease. There are many evidence-based guidelines for the management of LBP. The most common risk factor for development of LBP is previous LBP, heavy physical work, and psychosocial risk factors. Management of LBP includes identification of red flags, exclusion of specific secondary causes, and comprehensive musculoskeletal/neurological examination of the lower extremities. In uncomplicated LBP, imaging is unnecessary unless symptoms become protracted. Reassurance that LBP will likely resolve and advice to maintain an active lifestyle despite LBP are the cornerstones of management. Medications are provided not because they change the natural history of the disorder, but rather because they enhance the ability of the patient to become more active, and in some cases, to sleep better. The most commonly prescribed medications include nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. Although NSAIDs are a chemically diverse class, their similarities, efficacy, tolerability, and adverse effect profile have more similarities than differences. The most common side effects of NSAIDs are gastrointestinal. Agents with cyclo-oxygenase 2 selectivity are associated with reduced gastrointestinal bleeding, but problematic increases in adverse cardiovascular outcomes continue to spark concern. Fortunately, short-term use of NSAIDs for LBP is generally both safe and effective. This review will focus on the role of NSAIDs in the management of LBP.

Enhanced glycemic control with combination therapy for type 2 diabetes in primary care.

Type 2 diabetes mellitus is an increasingly common medical problem for primary care clinicians to address. Treatment of diabetes has evolved from simple replacement of insulin (directly or through insulin secretagogs) through capture of mechanisms such as insulin sensitizers, alpha-glucosidase inhibitors, and incretins. Only very recently has recognition of the critical role of the gastrointestinal system as a major culprit in glucose dysregulation been established. Since glycated hemoglobin A1c reductions provide meaningful risk reduction as well as improved quality of life, it is worthwhile to explore evolving paths for more efficient use of the currently available pharmacotherapies. Because diabetes is a progressive disease, even transiently successful treatment will likely require augmentation as the disorder progresses. Pharmacotherapies with complementary mechanisms of action will be necessary to achieve glycemic goals. Hence, clinicians need to be well informed about the various noninsulin alternatives that have been shown to be successful in glycemic goal attainment. This article reviews the benefits of glucose control, the current status of diabetes control, pertinent pathophysiology, available pharmacological classes for combination, limitations of current therapies, and suggestions for appropriate combination therapies, including specific suggestions for thresholds at which different strategies might be most effectively utilized by primary care clinicians.

Chronic pelvic pain in women: evaluation and management in primary care.

Chronic pelvic pain (CPP) in women is a common disorder, affecting as many as 15% of adult women, and often provides both a diagnostic and therapeutic challenge. Pain in CPP may originate directly from pelvic organs, or maybe referred from more distant tissue sites. A comprehensive medical history and physical examination should include special attention to gynecological, urological, gastrointestinal, psychiatric, myofascial, and neuromuscular systems. The effective management of CPP may involve comprehensive evaluations by specialists, psychologists, and multiple office visits. Physicians should address CPP as a chronic disease. Combining lifestyle modification with other traditional treatments produces better outcomes. Laboratory tests, transvaginal ultrasound, and laparoscopy may identify serious disease or provide significant reassurance to patient. Specific surgical procedures for various conditions and pain relief measures are beneficial in selected patients. A sensitive physician who is willing to spend adequate time and coordinate care with specialists can markedly diminish the suffering of these patients.

Improving management of type 2 diabetes mellitus: 5. Thiazolidinediones.

megtinitides, and chromium supplementation. T he thiazolidinediones (TZDs) are a relatively new class of oral antidiabetic agents. Because of their ability to improve insulin sensitivity, transport, and utilization at target tissues, they are being prescribed with great enthusiasm. Indeed, the TZDs address all three primary dysfunctions in patients with type 2 diabetes: insulin resistance, hyperinsulinemia, and hyperglycemia. The first TZD, ciglitazone, was developed in the early 1980s, but it was abandoned because of unacceptable side effects. At present, three TZDs are available in the United States for the treatment of type 2 diabetes: troglitazone, rosiglitazone, and pioglitazone (Table 1). Troglitazone was approved for use in 1997 and the other two in 1999.

Antithrombotic Therapy for Venous Thromboembolic Disease

The following recommendations summarize the anticoagulation guidelines from the seventh American College of Chest Physicians (ACCP) conference on antithrombotic and thrombolytic therapy and employ an evidence grading scale (summarized in Table 5), at the end of the chapter (1).