Obesity: concept,classification and diagnosis

Obesity is a chronic disease that is characterised by an increase of fat mass and as a result by an increase in weight. There is therefore an increase in the energy reserves of the organism in the form of fat. The term chronic is applied due to its forming part of the group of diseases that we are unable to cure with the therapeutic arsenal that is now available. From an anthropometric point of view, which is habitually used in the clinic, a person is considered to be obese with a Body Mass Index equal to or higher than 30 kg/m2. To be able to evaluate obesity account must be taken not only of the anthropometric aspects but also of the possible genetic factors; the causes of the disease must be studied and the possible existence of associated complications and diseases must be checked. Treatment must always be personalised and adapted to the characteristics and comorbidities presented by the patient. The dominant criteria favourable to therapeutic intervention in obesity are especially based on the demonstration that with a moderate loss of body weight (5-10 %) a notable improvement can be obtained in the comorbidity associated with obesity and in the quality of life of the obese patient.     

Vaginismus: a review of the literature on the classification/diagnosis, etiology and treatment

Vaginismus is currently defined as an involuntary vaginal muscle spasm interfering with sexual intercourse that is relatively easy to diagnose and treat. As a result, there has been a lack of research interest with very few well-controlled diagnostic, etiological or treatment outcome studies. Interestingly, the few empirical studies that have been conducted on vaginismus do not support the view that it is easily diagnosed or treated and have shed little light on potential etiology. A review of the literature on the classification/diagnosis, etiology and treatment of vaginismus will be presented with a focus on the latest empirical findings. This article suggests that vaginismus cannot be easily differentiated from dyspareunia and should be treated from a multidisciplinary point of view.     

Diabetes mellitus: current concepts in diagnosis, classification and coding

Diabetes mellitus (DM) is a chronic disorder of metabolism, which is commonly found in the Puerto Rican population. In this article the current concepts in diagnosis, classification and correct coding of DM are discussed. Since the cutoff point for diagnosing DM was lowered to 126 mg/dl in a fasting plasma glucose levels, many persons may be undiagnosed unless physicians are aware of this fact. Once diagnosed, strict control of the disease is mandatory to prevent the chronic diabetic complications. It is very important to classify and code the persons with DM accurately. This practice will help researchers, physicians, health insurance managers and other persons to assess the prevalence of DM and its complications. This will eventually lead to better management of this important disease.     

Insulin allergy: background, diagnosis and treatment

An allergic reaction develops in 2.4% of patients that use insulin. This ranges in severity from erythema and pruritus to life-threatening anaphylaxis. llergic reactions to insulin usually occur within a few hours after an injection and are usually due to a local or systemic type I IgE-mediated hypersensitivity reaction. Despite considerable research into the immunogenicity of insulin, this has not yet been clarified completely and allergic reactions to insulin still occur. A systematic diagnostic approach is essential for an adequate treatment plan. A blood test for anti-insulin antibodies and intradermal skin tests are of great importance. There are many options available for the treatment of insulin allergy and each patient must therefore be evaluated individually.     

Liver fibrosis: pathophysiology, diagnosis and treatment

The extracellular matrix deposition in the liver parenchyma is a major component of cirrhosis. A great deal of knowledge has been gathered in the past two decades regarding the regulation and dynamics of fibrogenesis, and based on these advances, a review is delivered on the pathophysiology, diagnosis and therapy of liver fibrosis. The key event in fibrogenesis is the activation of hepatic stellate cells, and in its mechanism, inflammation, oxidative stress, steatosis, cytokines, growth factors, enzymes and enzyme inhibitors play a pivotal role. The phenotypic response of activated stellate cells comprises proliferation, fibrogenesis, contractility, loss of vitamin A and matrix degradation. In the diagnosis of liver fibrosis, besides liver biopsy--as "golden standard"--recently non-invasive methods, such as imaging techniques, and mainly serum fibrosis markers and indices have widely been studied. Experimental and clinical data have proved the reversibility of fibrosis, and suggested that an effective antifibrotic treatment in the future may serve even for the prevention of cirrhosis.     

Nonalcoholic steatohepatitis: diagnosis, pathogenesis, treatment and prognosis

Nonalcoholic steatohepatitis and chronic viral hepatitis C are the two dominant liver diseases in the Netherlands. Hepatic steatosis is usually innocuous but in twenty percent of patients it develops into steatohepatitis. One-fifth of these patients develop liver cirrhosis and hepatocellular carcinoma can also be a consequence of the disease. Nonalcoholic steatohepatitis is characterized by macrovesicular steatosis, necroinflammation, loss ofhepatocytes and fibrosis. Nonalcoholic steatohepatitis often is associated with type 2 diabetes mellitus, hypertension, dyslipoproteinemia and obesity. Insulin resistance plays a major role in the pathogenesis of this disease. Drugs against insulin resistance can ameliorate nonalcoholic steatohepatitis. Gradual weight loss, a diet including polyunsaturated fatty acids and exercise are other important treatment components of this condition.     

Creutzfeldt-Jakob disease: diagnosis, incidence, prevention and treatment

Creutzfeldt-Jakob disease (CJD) is a rare, neurodegenerative disorder belonging to the spongiform encephalopathies. A variant form (vCJD) is most likely the result of infection with the agent that causes bovine spongiform encephalopathy (BSE). Diagnostic information can be obtained by EEG, testing cerebrospinal fluid for the presence of the 14-3-3 protein, MRI, brain biopsy, tonsil biopsy, and postmortem brain examination. Some tests, such as MRI and postmortem brain examination, can be used to distinguish between CJD and vCJD. Pathological prions in a tonsil biopsy are only found with vCJD. In the Netherlands, there are four known cases of iatrogenic CJD. On the basis of certain exposure to BSE via the food chain, cases of vCJD are also to be expected. Chloropromazine and mepacrine are known to inhibit the formation of pathological prion conformations, but clinical trials have not yet been carried out.     

Adolescent depression: diagnosis, treatment, and educational attainment

In this paper, I use nationally representative longitudinal data to examine adolescent depression and educational attainment. First, I examine the individual, family, and community-level determinants of adolescent depression, diagnosis, and treatment. I find that male and minority adolescents who score high on depression scales are less likely to be diagnosed as depressed or receive treatment than female and non-Hispanic white adolescents. Additionally, I find several community-level variables to be important determinants of depression, diagnosis, and treatment. Second, I examine the importance of adolescent depression for educational attainment. Although it is uncontroversial to expect a negative relationship, most previous research uses cross-sectional data, making it difficult to adequately determine the magnitude of the effect. I find that depressive symptoms are related to educational attainment along multiple margins: dropping out of high school, college enrollment, and college type. These relationships are only found for adolescent females, and there are several interesting results across income groups. Overall, these findings suggest that further attempts to diagnose and treat adolescents with depressive symptoms are needed and that additional treatment options may be required to combat the important relationship between adolescent depression and human capital accumulation for females.     

Malaria: control strategies, chemoprophylaxis, diagnosis, and treatment

Malaria caused by Plasmodium falciparum continues to be the principal medical threat to travelers in tropical zones. Eighty percent of malaria cases occur in sub-Saharan Africa. Prevention capacity nears 100%. In the event of infection, early diagnosis and bitherapy (treatment that includes two different active molecules) provide a nonfatal outcome. The greatest risk occurs in the weeks after returning home. The history of malaria has shown that it is important to anticipate the evolving nature of the disease and to be able to respond to it in a timely fashion. The efficiency of preventive treatments should lead toward the goal of zero malaria cases when dealing with travelers; however, virtually all empiric experience indicates that this goal rarely is reached.     

Ectopic bone formation: prevention, diagnosis and treatment

Two patients are described who developed heterotopic ossification after a minor trauma. The clinical symptoms, pathophysiology and treatment are discussed. We conclude that disabilities and handicaps will be limited by rehabilitation, which includes training of still available functions, and compensation for the lost functions by offering adaptive equipment and adjusting the circumstances. The treatment of patients with heterotopic ossification requires a multidisciplinary approach.     

Leishmaniasis: progress in diagnosis, treatment and prevention

Visceral leishmaniasis ranks second after malaria in the top 10 fatal parasitic diseases worldwide. Treatment is effective, but most patients live in developing countries where even basic health care is unavailable. Economic factors hamper a targeted approach, which should include the following: preventing transmission by distributing bednets; developing diagnostic tools that can be used in the field without a laboratory; developing new and affordable drugs; and evaluating different drug combinations and treatment schedules that may prevent the development of resistance, as has been done in tuberculosis, HIV and malaria.     

Massive haemoptysis: primary care, diagnosis and treatment

Massive haemoptysis is life-threatening because of asphyxiation from flooding of the central airways with blood. The first step in treatment includes airway protection, usually managed by intubation. Imaging may be inconclusive, and bronchoscopy--rigid or flexible--is essential to establish the site and cause of the bleeding. Bronchoscopy may be therapeutic in that a balloon catheter may be inserted in the bleeding airway in order to tamponade the source of bleeding. Embolisation of pathological bronchial arterial vessels is the treatment of choice in most cases; surgery is limited to causes that cannot be managed by the endovascular treatment modality, or to cases that fail to respond to embolisation.     

Nonfunctioning pituitary macroadenomas: diagnosis, treatment and follow-up

*Nonfunctioning pituitary adenomas are benign tumours characterised by the absence of hormone overproduction. *Clinical symptoms are caused by the mass effects of the tumour. The main symptoms are pituitary insufficiency, visual field defects, vision impairment and headache. *Treatment is unnecessary for tumours less than 1 cm, and an expectative approach can be used for some patients with larger tumours but no visual field defects. *Transsphenoidal surgery is indicated for patients with visual field defects. *Because nonfunctioning adenomas can recur, lifelong follow-up after treatment is necessary. *Poor quality of life has been reported in treated patients with nonfunctioning pituitary adenomas, which may be due to the intrinsic imperfections of hormonal replacement therapy.     

Haemangiomas and congenital vascular malformations: their classification and diagnosis

Mulliken and Glowacki's classification of peripheral blood- and lymph-vessel abnormalities is based on their clinical course and cellular characteristics, and is therefore clear to and readily usable by the practising physician. In order to make the diagnostic process more accessible, the Haemangiomas and Congenital Vascular Malformations Nijmegen working group has developed a system of diagnostic guidelines on the basis of this classification. The anamnesis should be directed at the following six distinguishing characteristics: presence of the anomaly at birth, growth, involution, change in volume, pain and outflow. The physical examination is directed at the following five characteristics: the possibility of emptying or pushing aside the anomaly, changes in volume during engorgement, murmur/'thrill'/pulsation, phleboliths, and hyper- or hypotrophy. If a diagnosis still cannot be made, then additional investigations may be carried out. Duplex scanning is usually sufficient for this purpose, after which the nature and extent of the malformation can be determined with MRI. On the basis of the results, the persons involved can be informed as to the prognosis of the malformation and a plan of treatment can be proposed.