Predictors of Early and Late Response to Esomezol and Lifestyle Modification in Adults With Laryngopharyngeal Reflux Disease: A Prospective, Multicenter, Open-Label Cohort Study.

OBJECTIVES: This study aimed to assess predictors of the response to varying durations of proton pump inhibitor (PPI) use and lifestyle modification treatment for laryngopharyngeal reflux disease (LPRD). METHODS: Between October 2014 and June 2016, a prospective, multicenter, open-label, single-cohort, intention-to-treat, observational study was conducted at eight referral hospitals across the Republic of Korea to examine predictors of early and late response to treatment in adult patients (age ≥19 years) with LPRD. Participants underwent standard treatment (PPI [Esomezol] and lifestyle modification) for 3 months. Response to treatment was defined as greater than 50% improvement in reflux symptom index score. The primary outcome was potential predictors of treatment response at 1 and 3 months. The secondary outcome was potential predictors distinguishing early from late responders. RESULTS: In total, 394 patients were enrolled. Improved sleep habits was a positive predictor (odds ratio [OR], 1.785; 95% confidence interval [CI], 1.06-3.007; P=0.029), while initial alcohol consumption (OR, 0.587; 95% CI, 0.355-0.969; P=0.037) and past medication history (OR, 0.438; 95% CI, 0.215-0.891; P=0.005) were negative predictors of response after 1 month of treatment. High pre-reflux finding score was a positive predictor (OR, 1.187; 95% CI, 1.049- 1.344; P=0.007), while male sex (OR, 0.516; 95% CI, 0.269-0.987; P=0.046), higher depression score (OR, 0.867; 95% CI, 0.784-0.958; P=0.005), and past thyroid hormone medication history (OR, 0.161; 95% CI, 0.033-0.788; P=0.024) were negative predictors of response after 3 months of treatment. Past medication history (OR, 0.438; 95% CI, 0.215-0.891; P=0.023) was the only negative predictor for early responders compared to late responders. CONCLUSION: Adult patients with LPRD and a history of prior medication use may require longer treatment durations to achieve a therapeutic response. Future research should explore the incorporation of diverse treatment approaches to improve treatment outcomes for patients exhibiting negative prognostic indicators.

Current Treatment Options, Including Diet, Exercise, and Medications: The Impact on Histology.

Paralleling the rise in obesity and diabetes, nonalcoholic fatty liver disease (NAFLD) is now the most prevalent chronic liver disease worldwide. Nonalcoholic steatohepatitis (NASH), the progressive form of NAFLD, may progress to cirrhosis, hepatic decompensation, and hepatocellular carcinoma. Despite its public health treat, no approved pharmacotherapies for NAFLD/NASH currently exist. Although the armamentarium of therapies for NASH is limited, current treatment options include life-style modification and the use of medications to treat metabolic comorbidities. This review addresses current approaches to the treatment of NAFLD/NASH, including the impact of diet, exercise, and available pharmacotherapies on the histologic features of liver injury.

'Daily 2-only meals and exercise' lifestyle modification for remission of type 2 diabetes mellitus: A therapeutic approach.

This case series has documented five patients diagnosed with type 2 diabetes (T2D), referred to the various Diabetes Reversal Centers of the 'World free of obesity and diabetes' campaign in Maharashtra, India. It demonstrates the therapeutic effects of lifestyle modification for remission of diabetes along with weight reduction and reversal of insulin resistance. This resulted in reduction of their glycated haemoglobin level, which signified the long-term effects of this lifestyle modification. Diabetes reversal by lifestyle modification is a healthier option and must be encouraged in all the patients in the pre-diabetes group (HbA1c- 5.7-6.4%) and those with newly diagnosed type 2 diabetes mellitus (HbA1c- >6.5%) without any complications, thus promoting good health seeking behaviour. There are pieces of evidence of complete diabetes reversal of the patients with HbA1c ranging from 8 to 15% by just lifestyle modification and also without any complications among the patients registered under the 'World free of obesity and diabetes' campaign. India is a low-middle-income country with prevalence of T2D on rise. It is thus necessary to provide the community with a cost-effective and sustainable solution for primary and secondary prevention of this lifestyle disease.

Knowledge, attitude, and practice regarding lifestyle modification among type 2 diabetes patients with cardiovascular disease at a Tertiary Hospital in Somalia.

Background: Diabetic was the eighth leading cause of death among both sexes and the fifth leading cause of death in women in 2012{WHO, 2016}. The main objective of this study is to identify the knowledge, attitude, and practice regarding lifestyle modification among type 2 DM with CVD at Mogadishu Somali Turkish Training and research hospital in Mogadishu, Somalia. Method: This study was hospital-based cross-sectional study conducted from type 2 Diabetic Mellitus patients with cardiovascular disease attended to Mogadishu Somali Turkish Training and Research Hospital for medical check-ups and regular medical treatments between September 2020 to August 2,0221. Results: A total of 384 patients were enrolled in the study. Out of 384 participants 221(57.6%) were females, while 163(42.4%) were males. The majority of the repondents, 261 (68%) fell within the age group of 60 years and above. Most of the participants (29.4%, n = 113) had no formal education. Interestingly, more than half 228(59.4%) of participants were employed, while near one-third of the respondents (34.1%, n = 131) belonged to the low-income group (<2,000,000SH).Concerning knowledge of the patients towards LSM of diabetic; the majority of the participants 68% (n = 261) had poor knowledge regarding knowledge questions, while 32% (n = 123) had good knowledge. Regarding to the level of attitude, 71.9% of respondents had a negative attitude toward the lifestyle modification of diabetics and the remaining 28.1% (n = 108) had negative attitude. More than two-thirds of participants 61.2% (n = 235) had a poor practice, while 38.8%(n = 149) respondents had a good practice regarding lifestyle modification.Finally A significant relationship was evaluated between Knowledge and Attitude (0.007*) and between Knowledge and Practices (P = 0.000**) suggesting that most participants had good knowledge associated with good attitude and practices correspondingly. Conclusion: The result of this study revealed, majority of type2 DM patients with CVD had poor knowledge, negative attitude and poor practices towards LSM. So, we recommend to all stake holders (Ministry of health, Health institution, health professionals, and national and international NGO) to improve KAP of the patients towards LSM.

Primary headache disorders in adolescents in North- and South-Tyrol: Findings of the EVA-Tyrol-Study.

OBJECTIVE: Assessment of the prevalence of primary headache disorders, associated risk factors and use of acute/preventive medication in a representative large sample of adolescents. METHODS: Within the EVA-Tyrol project, a community-based non-randomized controlled cross-sectional study, data was collected from adolescents aged 14-19 years from 45 sites across North-, East- and South Tyrol. Headaches were classified according to the latest ICHD-3 and assessed by headache specialists in face-to-face interviews. FINDINGS: Of 1923 participants 930 (48.4%) reported having headaches. Female to male ratio was 2:1. Migraine, tension-type headache and other headache were diagnosed in 10%, 30.2% and 8.2% respectively. Medication overuse was diagnosed in 3.4%, increasing up to 21.7% in participants with chronic headache. The use of preventative medication was not reported by any adolescent. Sleep disturbances (p < 0.05), alcohol consumption (p < 0.05), low physical activity (p < 0.01) and high screen time exposure (p < 0.01) were associated with an increased risk of headaches. CONCLUSION: We report high prevalence of primary headache disorders and medication overuse in a large community-based sample of teenagers. Acute and preventive non-drug and pharmacological treatments are not established due to lack of paediatric headache outpatient clinics. Promoting health education in teenagers and encouraging public awareness, including that of health care providers is pivotal.Trial registration: EVA-Tyrol has been retrospectively registered at clinicaltrials.gov under https://clinicaltrials.gov/ct2/show/NCT03929692 since April 29, 2019.

A community-level educational intervention trail to study the impact of life style modification in control of hypertension and diabetes- A non-randomized trial (Before and after intervention study without control).

Background: Dietary habits and physical inactivity are related to the risks of non-communicable diseases (NCDs), such as cardiovascular diseases, Diabetes and Hypertension, of which burdens are increasing all over the world. . It is essential that lifestyle modification and nondrug treatment measures such as health education, reduction in weight through regular exercise, changing in eating patterns is essential to control of Diabetes and Hypertension. Hence the present study is taken up with objectives. Objectives: 1. to assess and compare the impact of health education on life style modification (diet modification) on control of hypertension and diabetes of intervention group. 2. To assess and compare the practice of changed pattern of life style modification (diet modification) of known hypertensives and diabetics with continuous health education module and follow up. Methodology: This community-level education intervention trial to reduce the burden of Non communicable diseases (hypertension and diabetes) was conducted in coastal Karnataka. The study was taken up in a rural area of coastal Karnataka . A specific module for physical activity, diet modification separately for hypertension and diabetics was prepared by experts and this specific module trained social worker introduced diet modification, exercise pattern and habits to the village enrolled participants with involvement of family member who actually cooks at home for 2 months. Results: In the study subjects, it was observed that, the subjects who had higher systolic and diastolic pressure before intervention, changed to the lower levels after intervention. Though the change in blood pressure is not statistically significant. The intervention of overall lifestyle intervention, there was increased subjects with Hb1Ac in the range of 7-9% and reduced subjects with Hb1Ac of >9.1%. Though it was not statistically significant. There was significant improvement in the mean duration of physical activity in order to control the hypertension and Diabetes mellitus. We also noticed that there was reduction in the sedentary hours, though the difference was not statistically significant. Conclusion: Life style intervention with continuous monitoring is essential to bring down the blood pressure and diabetic sugars. We donot need doctors alone to bring the life style modifications and the health workers can initiate it in the villages. The intervention of life style modifications have brought in better care and quality of life in the villages compared to control village.

Concurrent smoking and alcohol consumers had higher triglyceride glucose indices than either only smokers or alcohol consumers: a cross-sectional study in Korea.

BACKGROUND: The triglyceride glucose (TyG) index is a noninsulin-based marker for insulin resistance (IR) in general practice. Although smoking and heavy drinking have been regarded as major risk factors for various chronic diseases, there is limited evidence regarding the combined effects of smoking and alcohol consumption on IR. This study aimed to investigate the relationship between the TyG index and smoking and alcohol consumption using two Korean population-based datasets. METHODS: This study included 10,568 adults in the Korean National Health and Nutrition Examination Survey (KNHANES) and 9586 adults in the Korean Initiatives on Coronary Artery Calcification (KOICA) registry datasets. Multivariate logistic analysis was conducted to explore the relationship between smoking and alcohol consumption and the TyG index. To assess the predictive value of smoking and alcohol consumption on high TyG index, the area under the curve (AUC) were compared and net reclassification improvement (NRI) and integrated discrimination improvement (IDI) analyses were derived. RESULTS: The combined effect of smoking and alcohol consumption was an independent risk factor of a higher TyG index in the KNHANES (adjusted odds ratio: 4.33, P < .001) and KOICA (adjusted odds ratio: 1.94, P < .001) datasets. Adding smoking and alcohol consumption to the multivariate logistic models improved the model performance for the TyG index in the KNHANES (AUC: from 0.817 to 0.829, P < .001; NRI: 0.040, P < .001; IDI: 0.017, P < .001) and KOICA (AUC: from 0.822 to 0.826, P < .001; NRI: 0.025, P = .006; IDI: 0.005, P < .001) datasets. CONCLUSIONS: Smoking and alcohol consumption were independently associated with the TyG index. Concurrent smokers and alcohol consumers were more likely to have a TyG index that was ≥8.8 and higher than the TyG indices of non-users and those who exclusively consumed alcohol or smoking tobacco.

Lifestyle Intervention for Cardiovascular Disease Risk Factors in Jeddah, Saudi Arabia.

Background Cardiovascular disease (CVD) remains the major cause of global mortality. Applying a comprehensive interventional program may reduce the incidence of cardiovascular disease and its complications. Objective This study compared the effects of a three-month intervention involving lifestyle modification and physical activity with standard care in women ≥30 years having a moderate to high risk of CVD, with respect to improving physical activity and cardiovascular disease risk factors at the National Guard Residential City in Jeddah, Saudi Arabia, in 2015. Methods The effects of this community-based lifestyle program were assessed through a randomized controlled trial from January 1st to September 6th, 2015. Women in the intervention group (n = 31) received health education, exercise training, and diet counselling as individuals and in groups according to the participant's risk. Women in the control group (n = 28) received one health education session at the screening site. The primary outcome was the proportion of women with moderate Framingham risk scores (FRS) reducing their risk by 10% and the proportion of women with high FRS reducing their risk by 25%. The secondary outcome was the proportion of women reducing their risk by ≥1 risk category. Results The mean participant age was 42 ± 8 years. At three-month's follow-up, reductions were greater in the intervention group and the difference between groups was statistically significant (p < 0.05). Lifestyle intervention program significantly reduced systolic blood pressure (-9.2 mmHg), blood glucose (-45 mg/dL) and Framingham risk score (-13.6). Linear regression analysis revealed a significant improvement in the Framingham risk score (p < 0.01). Conclusion In a population of women with moderate-to-high risk of CVD, a personalized lifestyle modification program showed positive association in improving the 10-year cardiovascular Framingham risk score after three months.

Eruptive xanthoma associated with severe hypertriglyceridemia and poorly controlled type 1 diabetes mellitus.

Eruptive xanthoma is characterized by yellowish skin papules encircled by an erythematous halo and associated with severe hypertriglyceridemia above 2,000 mg/dl. Hypertriglyceridemia can be caused by primary genetic mutations, secondary causes, such as uncontrolled diabetes, obesity, alcohol overuse, or combinations of both. Eruptive xanthoma can serve as an important clinical indicator of underlying systemic conditions (e.g. hypertriglyceridemia and uncontrolled diabetes mellitus). It is important for clinicians to recognize it to prevent further complications such as pancreatitis and cardiovascular disease.

Evaluation of a Community-Based Diabetes Prevention Program in Thailand: A Cluster Randomized Controlled Trial.

OBJECTIVES: Lifestyle interventions have been shown to effectively reduce the incidence of diabetes, but evidence from middle-income countries is scarce. We evaluated the effectiveness of a lifestyle program to prevent diabetes in primary-care settings in Thailand. METHODS: A matched-pair cluster randomized controlled trial was conducted in 68 primary care units in 8 provinces. The primary care units were randomly assigned to intervention or control arms. Individuals aged 30 to 65 years with impaired oral glucose tolerance were recruited and followed up for 2 years. The intervention included periodic group-based activities on healthy lifestyle behaviors; the control group received a one-time education program. The primary outcome was the incidence rate of type 2 diabetes at 24 months after the intervention. RESULTS: A total of 1903 individuals participated (873 in the control group and 1030 in the intervention group). At baseline, participants' characteristics did not differ between groups. After 24 months, the incidence rates (per 100 person-year) of diabetes was 12.1% (95% CI 10.7% to 13.8%) in the intervention group, and 16.6% (95% CI 14.6 to 18.8%) in the control group ( P < .001). Overall, the adjusted hazard ratio for diabetes incidence was 0.72 (95% CI 0.60 to 0.86). A mean body weight reduction of 1.5 kg was observed in the intervention group, whereas, an increase of 0.4 kg was observed in the control group ( P < .001). CONCLUSION: A community-based lifestyle modification through participatory group activities can prevent or delay the incidence of diabetes among Thai populations with impaired glucose tolerance.

Non-alcoholic fatty liver disease and lifestyle modifications, focusing on physical activity.

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, and the prevalence of non-alcoholic steatohepatitis (NASH) with fibrosis is increasing as the population with NAFLD ages. To date, lifestyle modifications including weight loss, increased physical activity, and dietary changes remain the treatment of choice for NAFLD because there are no approved effective pharmacologic agents. Increased physical activity has therapeutic effects on NAFLD by reducing hepatic fat independent of weight reduction. Indeed, even minimal physical activity below the recommended threshold may have a beneficial impact on NAFLD. Aerobic activity and resistance training have similar effects on NAFLD. Universal recommendations for the optimal intensity and dose of physical activity have not been established. Therefore, physical activity should be tailored based on a patient's clinical characteristics, comorbidities, and fitness capacity. Physical activity also prevents the development of NAFLD and may represent a valuable strategy for reducing the public health burden. However, there are insufficient data supporting the effects of physical activity on the progression of non-alcoholic fatty liver to NASH with advanced fibrosis, and on extrahepatic disease-related morbidity and mortality. In this paper, we review the role of physical activity in the management of NAFLD.

Nutritional management in women with polycystic ovary syndrome: A review study.

Polycystic ovary syndrome (PCOS) is endocrine disorder in women of reproductive age, which leads to reproductive, hormonal and metabolic abnormalities. Due to the presence of insulin resistance, PCOS increases the risk of chronic diseases like type 2 diabetes, hypertension, lipid disorders, cardiovascular diseases and malignancies such as breast and endometrial cancer. The actual cause of this syndrome is unknown but environmental factors such as dietary habits play an important role in prevention and treatment and lifestyle modifications are the most important therapeutic strategies in these patients. The approach of the diet therapy in these patients must be to reach specific goals such as improving insulin resistance, metabolic and reproductive functions that will be possible through the design of low-calorie diet to achieve weight loss or maintaining a healthy weight, limit the intake of simple sugars and refined carbohydrates and intake foods with a low glycemic index, reduction of saturated and trans fatty acids and attention to possible deficiencies such as vitamin D, chromium and omega-3. Given the prevalence of overweight and obesity and insulin resistance, a relatively low reduction in weight, about 5%, can improve problems such as insulin resistance, high levels of androgens, reproductive system dysfunctions and fertility in these women.

Medical Management of Chronic Pancreatitis: What Can Physicians Do? / 대한췌담도학회지

Chronic pancreatitis is characterized by the progressive inflammation and irreversible fibrosis of pancreas causing pancreatic dysfunctions and various complications. The most common symptom is abdominal pain. In addition various complications such as pseudocyst, biliary or duodenal obstruction, pancreatic ascites, splenic vein thrombosis and pseudoaneurysm can develop according to the degree of inflammation or the progression of disease. So, management of chronic pancreatitis needs multidisciplinary approach in many cases. The treatment method can be divided into life style modifications, medications, endoscopic or radiological interventions and surgeries. In most cases, the specific treatments are recommended not only by the evidence-based guidelines but also by the experts' opinions due to the lack of randomized controlled trials with sufficient number of patients. Life style modifications and medication for the pain and the pancreatic exocrine insufficiency will be addressed in this section.

Randomized Evaluation of the Effectiveness of a Structured Educational Program for Patients With Essential Hypertension.

BACKGROUND: Adherence to medication and lifestyle interventions are essential keys for the management of hypertension. In this respect, a structured educational program for hypertensive patients has got remarkable merits (herz.leben). In order to determine the isolated effect of participation in the educational program, neglecting the possible impact of more intense care, this prospective multicenter randomized controlled study was designed (NCT00453037). METHODS: A total of 256 patients in 13 centers were enrolled and randomly assigned to 2 groups (G). G-I (n = 137) underwent the educational program immediately (T-0), G-II (n = 119) after 6 months (T-6). Follow-up visits were done after 6 (T-6) and 12 (T-12) months. Primary endpoint was a difference in office blood pressure (BP) at T-6, when only G-I had undergone the educational program. RESULTS: Patients' baseline characteristics were comparable. At T-6, systolic office and home BP were significantly lower in G-I compared to G-II: office BP systolic 139 (134-150) mm Hg vs. 150 (135-165) mm Hg (P < 0.01); diastolic 80 (76-85) mm Hg vs. 84 (75-90) mm Hg (ns); home BP systolic 133 (130-140) mm Hg vs. 142 (132-150) mm Hg (P < 0.01); diastolic 80 (75-85) mm Hg vs. 80 (76-89) mm Hg (ns)). At T-12, when all patients had undergone the educational program differences in BP disappeared. CONCLUSION: The results of this multicenter randomized controlled study provide significant evidence for benefit by participation in a structured educational program. Positive effects seem to be mediated by better adherence and life style changes due to higher levels of information and patient empowerment. Therefore, educational strategies should be considered as standard of care for hypertensive patients.

[Follow-up care of patients after heart attack]. / Nachsorge von Herzinfarktpatienten in der Hausarztpraxis.

Survivors of a myocardial infarction are at increased risk for future cardiac events, including recurrent infarction, heart failure, arrhythmia, stroke, and sudden cardiac death. The primary care physician needs to be aware of the potential risks and complications facing these patients. Secondary preventive measures after myocardial infarction include an optimal medical therapy (dual antiplatelet therapy, Statin, ACE-inhibitor, and in most cases a beta-blocker) and life style modifications (quit smoking, regular physical activity, Mediterranean-style diet). Patients should be informed about how to recognize and react to cardiac symptoms.

Rapid Reversal of Liver Steatosis With Life Style Modification in Highly Motivated Liver Donors.

BACKGROUND: Liver steatosis is the leading cause of donor rejection in living donor liver transplantation. Rapid weight loss is difficult to achieve in a short period of time, moreover it has been thought to worsen liver histology. METHODS: Donors who had significant steatosis based on liver biopsy were recommended 1200 Kcal/day and a minimum of 60 min/day moderate cardio training. Two patients were advised statins for dyslipidemia. None of the donors had metabolic syndrome. A second ultrasound guided liver biopsy was done at 28 ± 10 days. Donors with nonalcoholic steatohepatitis/fibrosis or >30% steatosis were not included. RESULTS: From July 2010 to January 2015, 16 donors were advised aggressive life style modification after initial biopsy; 15 (10 males, age 27.5 ± 6.5 years, baseline body mass index 28.4 ± 2.1 Kg/M(2)) successfully reduced weight and 14 underwent donation after favorable second biopsy. Mean weight loss was 7 ± 4.3 kg (8.4 ± 4.6%). Second liver biopsy was done at 28 ± 10 days, there was decrease in steatosis in all but one including normalization of liver biopsy in 7 donors. Three donors had mild inflammation on first biopsy and they had improvement in second biopsy. All the donors and their recipients had an uneventful post-operative course. CONCLUSION: Steatosis can be reversed in a short duration by aggressive life style modifications in highly motivated liver donors.

Cardiovascular results of an individually controlled complex prevention.

UNLABELLED: Lifestyle modifications (increased level of physical activity, favourable nutrition, and stress management) are important factors in the prevention of and the therapy for cardiovascular (CV) diseases. OBJECTIVES: The effects of an individualized, half-year long exercise program on CV risk factors were investigated in 50 patients with moderately high CV risk factors. PATIENTS AND METHODS: 75 subjects participated in the study. After the eleventh week of regular training, members of Group A performed 55-65 minutes of exercise at 4-5 times a week, while patients in Group B took part in 45-55 minute training sessions at 2-3 times a week. Activities were monitored using POLAR devices and controlled by a cardiologist and an exercise training expert. Members of the control group (C)were also affected by risk factors, they, however, were not involved in any physical activity. RESULTS: A marked improvement was seen in performance level (62% in Group A, 38% in Group B). There was a decrease in the LDL cholesterol level (30% and 21%), total cholesterol (16% and 14%), triglyceride (23% in both groups), and an increase in the HDL-cholesterol level (53% and 26%). Body mass (BM) decreased in both groups (8.7% and 5%).In addition, a decrease was also seen in the resting heart rate (HR) (9.6% and 4.5%) and blood pressure (BP: systolic 8.5% and 5.5 %, diastolic 7% and 4.7%). CONCLUSIONS: In persons affected by CV risk factors, lifestyle modification with personal, HR controlled complex (cardio and resistance) aerobic training effectively decreased CV risk factors and strongly improved state of health and quality of life.

Acrocyanosis: an overview.

INTRODUCTION: It is a functional peripheral vascular disorder characterized by bluish discoloration of skin and mucous membrane due to diminished oxyhemoglobin. It may be due to central or local tissue oxygenation defects. It is a painful episodic disorder, where trophic changes and ulceration are very rare except in necrotizing variant. By definition, it refers to persistent abnormally deep blue or cyanotic discoloration of skin over extremities (hand and feet most commonly) due to decreased oxyhemoglobin. ETIOLOGY: It can be both primary and secondary to psychiatric, neurologic, autoimmune, infective, metabolic and other causes. The existing hypothesis suggests the prevailing role of vasospastic reaction over possible blood rheology impairment.[1] As per the current line of thinking, it is due to chronic vasospasm of small cutaneous arteries, and arterioles along with compensatory dilatation in the capillary and post capillary venules causes cyanosis and sweating. CLINICAL FEATURES: Acrocyanosis is an uncommon condition. It usually presents with coolness and violaceous dusky discolorations of hands and less frequently the feet. Other peripheral part like ear, nose, lips and nipple can also be affected.[2] The changes may be transient after cold exposure but frequently persist during winter and even in summer. MANAGEMENT: There is no standard and curative medical or surgical treatment of acrocyanosis. In mild cases, it is unnecessary to give any drug treatment. Life style modification, dietary and hygiene counseling, avoidance of cold and reassurance that the bluish skin discoloration does not indicate any serious illness is all that is necessary.

Management of diabetic hypertensives.

Hypertension occurs twice as commonly in diabetics than in comparable nondiabetics. Patients with both disorders have a markedly higher risk for premature microvascular and macrovascular complications. Aggressive control of blood pressure (BP) reduces both micro- and macrovascular complications. In diabetic hypertensives, angiotensin converting enzyme inhibitors (ACEIs) are the first line in management of hypertension, and can be replaced by angiotensin II receptor blockers (ARBs) if patients are intolerant of them. Recent studies suggest ARBs to be on par with ACEI in reducing both macro- and microvascular risks. Adding both these agents may have a beneficial effect on proteinuria, but no extra macrovascular risk reduction. Thiazides can also be used as first line drugs, but are better used along with ACEI/ARBs. Beta-blockers [especially if the patient has coronary artery disease] and calcium channel blockers are used as second line add-on drugs. Multidrug regimens are commonly needed in diabetic hypertensives. Achieving the target BP of <130/80 is the priority rather than the drug combination used in order to arrest and prevent the progression of macro- and microvascular complications in diabetic hypertensives.