Weight control and nutrition: knowing when to intervene.

The average weight of American adults is increasing, despite vast sums being spent on attempts at weight loss. Above-average weight in midlife is associated with increased morbidity and mortality as patients age. Nonetheless, there is confusion about what are "desirable" weight levels. Commonly-used actuarial tables do not account for the modest, normal weight gains seen at midlife; therefore, age-adjusted tables are recommended. Treatment of obesity, one of the most common malnutrition disorders, is difficult, requires a "chronic disease" approach, and should be considered in the context of other risks to health.

Prescribing for older patients: how to avoid toxic drug reactions.

As a group, persons age 65 and older are the largest consumers of pharmaceuticals, accounting for 30% of prescription drugs and 40% of over-the-counter medications. Many elderly patients take multiple medications for a variety of concurrent medical conditions. The use of two or more drugs, combined with widely varying degrees of disease-related and physiologic impairment of function, can lead to unintended adverse reactions and even death. The physician can help to minimize adverse drug reactions and improve outcomes by being aware of the principles of clinical pharmacology, the characteristics of specific drugs, and the special physical, psychological, and social needs of older patients.

Bivalvular endocarditis complicating pregnancy. A case report and literature review.

A twenty-nine-year old woman with a history of rheumatic fever and both mitral and tricuspid valve prolapse (without cardiac effects on the echocardiogram) presented with Streptococcus viridans infective endocarditis of both the tricuspid and mitral valves at seventeen weeks' gestation. Twelve weeks before admission she underwent a dental curettage and received presumably adequate antibiotic prophylaxis. The present case was successfully managed by means of aggressive antibiotic therapy appropriate for endocarditis, with adequate and appropriate monitoring of minimal inhibitory concentration and peak and trough levels. This case exhibits the appropriate management in the three phases of therapy for valvular disease, ie prevention, treatment, and subsequent prevention of sequelae, prior to vaginal delivery in a patient with endocarditis. The pregnancy resulted in a term vaginal delivery, without maternal or fetal morbidity.

Gastrointestinal blood loss in arthritic patients receiving chronic dosing with etodolac and piroxicam.

Etodolac, a new anti-inflammatory analgesic drug found to be effective in treating arthritis in a dose range of 100 to 300 mg bid, has been shown to induce significantly less gastrointestinal microbleeding in normal men than several other NSAIDs. In this study, the effect on gastrointestinal blood loss of high-dose etodolac, 300 and 500 mg bid, versus piroxicam at its normal therapeutic dose of 20 mg qd, was investigated by the 51Cr method in 23 men with osteo- or rheumatoid arthritis. Placebo periods preceded and followed 28 days of active drug treatment. Blood and stool analyses were performed by an analyst not aware of drug assignment or study design. Patients receiving piroxicam, but not those receiving either dose of etodolac, had a significantly higher mean level of fecal blood loss in the active treatment phase compared with the pretreatment placebo level (p less than 0.01). Further, microbleeding was significantly greater for the piroxicam group during treatment than for either of the etodolac groups (p less than 0.01). There were no significant differences in fecal blood loss between the two groups receiving etodolac compared with pretreatment. Even at doses two to three times those found effective in the treatment of arthritis, etodolac produces no increase in fecal blood loss, in contrast to blood loss seen with the recommended dose of piroxicam. Fecal blood loss in osteoarthritic patients, not receiving an NSAID, was similar to normal subjects in previous studies.

Etodolac compared with aspirin: an endoscopic study of the gastrointestinal tracts of normal volunteers.

Forty-eight normal men participated in a 14-day, single blind, single center, multiple dose study of gastric irritation using endoscopy. Subjects were randomly assigned to one of 4 treatment groups after a one week lead-in period, as follows: etodolac 200 mg BID, 400 mg BID, 600 mg BID, or aspirin 975 mg QID. Etodolac at all dose levels produced significantly (p less than or equal to 0.0001) less gastrointestinal irritation than aspirin as assessed by endoscopic examination of the gastric and duodenal sites. There were no significant differences among the 3 etodolac groups.

Gastrointestinal microbleeding associated with the use of etodolac, ibuprofen, indomethacin, and naproxen in normal males.

Etodolac, a nonsteroidal antiinflammatory and analgesic drug, was used in a randomized, parallel group, open-label design study, with stool analysis conducted in a blind fashion, to compare its effect in normal men in doses of 400 mg (N = 11) and 600 mg (N = 12) b.i.d. on gastrointestinal microbleeding with that of 600 mg ibuprofen, q.i.d. (N = 12), 50 mg indomethacin in the morning, 50 mg at noon, and 100 mg h.s. (N = 9), and 375 mg naproxen b.i.d. (N = 9). Etodolac was given at about 2 1/2 and 3 1/2 times the mean effective dose used for treating patients with rheumatoid arthritis. The other drugs were given at their manufacturers' maximum recommended doses. Lead-in placebo was given for one week, active drug for one week, and washout placebo for one week. Fecal blood loss was measured by the 51Cr-tagged red cell method, and was averaged over days 4-7 (baseline), 11-14 (treatment period), and 17-20 (washout). The mean increase in blood loss for the treatment period for the 400 mg etodolac b.i.d. group (0.13 ml) and 600 mg etodolac b.i.d. group (0.10 ml) was significantly less (P = 0.001) than the corresponding values for ibuprofen (1.14 ml), indomethacin (1.20 ml), and naproxen (0.87 ml). There was no tendency for greater blood loss at higher doses of etodolac. Etodolac at doses in excess of the mean effective dose in osteoarthritis and rheumatoid arthritis caused significantly less microbleeding in normal male volunteers during the seven-day treatment period than the other drugs tested, and not clinically more than that occurring during baseline placebo.

Effect of cimetidine on the absorption of vitamin B12.

The effect of cimetidine on the absorption of orally administered crystalline or food (egg yolk-bound) vitamin B12 (B12) was studied in 13 patients. Absorption or crystalline B12 was normal and not significantly changed by cimetidine. In contrast, the uptake of food-bound B12 decreased in all patients, from a mean of 5.3% without the drug to 2.5% after it, a fall of 53% (p less than 0.0001). This impairment of B12 absorption raises the possibility that long-term, full-dose therapy with cimetidine may produce B12 deficiency similar to that seen in other hypochlorhydric states. Our data indicate that cimetidine-induced B12 malabsorption would not be detected by the standard Schilling test.