Harrison interal medicine

Making a Treatment Plan From information on the extent of disease and the prognosis and in conjunction with the patient's wishes, it is determined whether the treatment approach should be curative or palliative in intent. Cooperation among the various professionals involved in cancer treatment is of the utmost importance in treatment planning.

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Tumor markers may be useful in patient management in certain tumors. Response to therapy may be difficult to gauge with certainty. However, some tumors produce or elicit the production of markers that can be measured in the serum or urine and, in a particular patient, rising and falling levels of the marker are usually associated with increasing or decreasing tumor burden, respectively. Some clinically useful tumor markers are shown in Table 77-5.

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Defining the Extent of Disease and the Prognosis The first priority in patient management after the diagnosis of cancer is established and shared with the patient is to determine the extent of disease. The curability of a tumor usually is inversely proportional to the tumor burden. Ideally, the tumor will be diagnosed before symptoms develop or as a consequence of screening efforts (Chap. 78). A very high proportion of such patients can be cured.

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Cancer Around the World In 2002, 11 million new cancer cases and 7 million cancer deaths were estimated worldwide. When broken down by region of the world, ~45% of cases were in Asia, 26% in Europe, 14.5% in North America, 7.1% in Central/South America, 6% in Africa, and 1% in Australia/New Zealand (Fig. 77-3). Lung cancer is the most common cancer and the most common cause of cancer death in the world. Its incidence is highly variable, affecting only 2 per 100,000 African women but as many as 61 per 100,000 North American men. Breast cancer is the second...

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Harrison's Internal Medicine Chapter 77. Approach to the Patient with Cancer Approach to the Patient with Cancer: Introduction The application of current treatment techniques (surgery, radiation therapy, chemotherapy, and biological therapy) results in the cure of nearly two of three patients diagnosed with cancer. Nevertheless, patients experience the diagnosis of cancer as one of the most traumatic and revolutionary events that has ever happened to them.

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Recurrent episodes of binge eating, which is characterized by the consumption of a large amount of food in a short period of time and a feeling that the eating is out of control. Recurrent inappropriate behavior to compensate for the binge eating, such as self-induced vomiting. The occurrence of both the binge eating and the inappropriate compensatory behavior at least twice weekly, on average, for 3 months. Overconcern with body shape and weight.

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An algorithm for basic treatment decisions regarding patients with anorexia nervosa or bulimia nervosa. Based on the American Psychiatric Association's practice guidelines for the treatment of patients with eating disorders.

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Refusal to maintain body weight at or above a minimally normal weight for age and height. (This includes a failure to achieve weight gain expected during a period of growth leading to an abnormally low body weight.) Intense fear of weight gain or becoming fat. Distortion of body image (e.g., feeling fat despite an objectively low weight or minimizing the seriousness of low weight). Amenorrhea. (This criterion is met if menstrual periods occur only following hormone—e.g., estrogen—administration.

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Physical Features Patients with AN typically have few physical complaints but may note cold intolerance. Gastrointestinal motility is diminished, leading to reduced gastric emptying and constipation. Some women who develop AN after menarche report that their menses ceased before significant weight loss occurred. Weight and height should be measured to allow calculation of body mass index (BMI; kg/m2). Vital signs may reveal bradycardia, hypotension, and mild hypothermia. Soft, downy hair growth (lanugo) sometimes occurs, and alopecia may be seen.

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Table 76-1 Common Characteristics of Anorexia Nervosa and Bulimia Nervosa Anorexia Nervosaa Bulimia Nervosa Clinical Characteristics Onset Mid-adolescence Late adolescence/early adulthood Female:male 10:1 10:1 Lifetime prevalence 1% 1–3% in women Weight Markedly decreased Usually normal Menstruation Absent Usually normal Binge eating 25–50% Required diagnosis for Mortality 5% per decade Low Physical and Laboratory Findingsa Skin/extremities Lanugo Acrocyanosis Edema Cardiovascular Bradycardia Hypotension Gastrointestinal Salivary enlargement gland S...

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Harrison's Internal Medicine Chapter 76. Eating Disorders Eating Disorders: Introduction Anorexia nervosa and bulimia nervosa are characterized by severe disturbances of eating behavior. The salient feature of anorexia nervosa (AN) is a refusal to maintain a minimally normal body weight. Bulimia nervosa (BN) is characterized by recurrent episodes of binge eating followed by abnormal compensatory behaviors, such as self-induced vomiting. AN and BN are distinct clinical syndromes but share certain features in common.

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The three restrictive-malabsorptive bypass procedures combine the elements of gastric restriction and selective malabsorption. These procedures include Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion (BPD), and biliopancreatic diversion with duodenal switch (BPDDS) (Fig. 75-2). RYGB is the most commonly performed and accepted bypass procedure. It may be performed with an open incision or laparoscopically.

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Peripherally Acting Medications Orlistat (Xenical) is a synthetic hydrogenated derivative of a naturally occurring lipase inhibitor, lipostatin, produced by the mold Streptomyces toxytricini. Orlistat is a potent, slowly reversible inhibitor of pancreatic, gastric, and carboxylester lipases and phospholipase A2, which are required for the hydrolysis of dietary fat into fatty acids and monoacylglycerols. The drug acts in the lumen of the stomach and small intestine by forming a covalent bond with the active site of these lipases.

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Physical Activity Therapy Although exercise alone is only moderately effective for weight loss, the combination of dietary modification and exercise is the most effective behavioral approach for the treatment of obesity. The most important role of exercise appears to be in the maintenance of the weight loss. Currently, the minimum public health recommendation for physical activity is 30 min of moderate intensity physical activity on most, and preferably all, days of the week.

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Lifestyle Management Obesity care involves attention to three essential elements of lifestyle: dietary habits, physical activity, and behavior modification. Because obesity is fundamentally a disease of energy imbalance, all patients must learn how and when energy is consumed (diet), how and when energy is expended (physical activity), and how to incorporate this information into their daily life (behavior therapy). Lifestyle management has been shown to result in a modest (typically 3– 5 kg) weight loss compared to no treatment or usual care.

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Assessing the Patient's Readiness to Change An attempt to initiate lifestyle changes when the patient is not ready usually leads to frustration and may hamper future weight-loss efforts. Assessment includes patient motivation and support, stressful life events, psychiatric status, time availability and constraints, and appropriateness of goals and expectations. Readiness can be viewed as the balance of two opposing forces: (1) motivation, or the patient's desire to change; and (2) resistance, or the patient's resistance to change.

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Excess abdominal fat, assessed by measurement of waist circumference or waist-to-hip ratio, is independently associated with higher risk for diabetes mellitus and cardiovascular disease. Measurement of the waist circumference is a surrogate for visceral adipose tissue and should be performed in the horizontal plane above the iliac crest. Cut points that define higher risk for men and women based on ethnicity have been proposed by the International Diabetes Federation (Table 75-3).

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Harrison's Internal Medicine Chapter 75. Evaluation and Management of Obesity Evaluation and Management of Obesity: Introduction Over 66% of U.S. adults are currently categorized as overweight or obese, and the prevalence of obesity is increasing rapidly throughout most of the industrialized world. Based on statistics from the World Health Organization, overweight and obesity may soon replace more traditional public health concerns such as undernutrition and infectious diseases as the most significant contributors to ill health.

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The average total daily energy expenditure is higher in obese than lean individuals when measured at stable weight. However, energy expenditure falls as weight is lost, due in part to loss of lean body mass and to decreased sympathetic nerve activity. When reduced to near-normal weight and maintained there for a while, (some) obese individuals have lower energy expenditure than (some) lean individuals. There is also a tendency for those who will develop obesity as infants or children to have lower resting energy expenditure rates than those who remain lean.

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Cushing's Syndrome Although obese patients commonly have central obesity, hypertension, and glucose intolerance, they lack other specific stigmata of Cushing's syndrome (Chap. 336). Nonetheless, a potential diagnosis of Cushing's syndrome is often entertained. Cortisol production and urinary metabolites (17OH steroids) may be increased in simple obesity.

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