Why, when and how to initiate insulin therapy in patients with type 2 diabetes.

Type 2 diabetes is characterised by insulin resistance and progressive beta-cell deterioration. As beta-cell function declines, most patients with type 2 diabetes will require insulin therapy. Clinical studies show that tight control of blood glucose levels prevents the development of the microvascular and macrovascular complications caused by diabetes. Insulin is the most potent drug currently available to achieve tight glycaemic control; however, often it is not used early or aggressively enough for patients to achieve the glycaemic targets needed to prevent chronic complications. New basal insulin analogues and premixed insulin analogues, which have more physiological time-action profiles compared with human insulin formulations, offer flexibility and convenience, thereby improving quality of life. It is crucial that doctors initiate insulin therapy as soon as other diabetes therapies are no longer effective. This article reviews the improvements provided by basal insulin analogues, premixed insulin analogues, and insulin delivery systems; provides sample algorithms for initiating and titrating the various insulin analogue preparations; and discusses how to individualise treatment regimens to maximise outcomes in patients with type 2 diabetes.

Poor blood pressure control: what physicians can do to improve it.

Poor control of hypertension is common, but its causes are not always easy to discern and thus are often not readily corrected. A well-known cause of poor blood pressure control is poor patient adherence to therapy. Reliance on short-acting antihypertensive drugs may contribute to both problems. According to various clinical trials, more even blood pressure control can be achieved with long-acting antihypertensive agents administered once daily. Given these agents' ease of dosing and persistence of effect, their use is likely to improve adherence and control. Physicians can also have a positive impact by providing patient education that stresses the importance of patients' long-term adherence to their prescribed drug regimen even in the absence of symptoms. Moreover, they can create an atmosphere in which patients feel free to voice their concerns about their disease, ask questions about their drug regimen, and discuss any adverse effects or recommended lifestyle changes that may be undermining their adherence to the therapy prescribed.

Depression.

Depression often presents with physical symptoms, primarily fatigue, pain, or sleep disturbance. Depressed mood may or may not be present. Supportive counseling and pharmacotherapy are more effective than either modality alone. The newer drugs are better tolerated than earlier agents, and they achieve much greater patient adherence. Depression is considered a chronic disease. The likelihood of recurrence increases with the number of episodes, often calling for prolonged maintenance of medication. Most patients with mild to moderate depression can be effectively managed by their primary care physician, with referral required only for those who are unresponsive to therapy or who are suicidal.

Scope and consequences of peptic ulcer disease. How important is asymptomatic Helicobacter pylori infection?

H pylori infection is so common as to seem ubiquitous in many areas of the world. Transmission is believed to be primarily person to person. The pathogen invariably damages the gastric mucosa, resulting in both structural and functional abnormalities. It causes histologic gastritis and is critical in the pathogenesis of the gastritis-associated diseases, namely, gastric ulcer, duodenal ulcer, gastric adenocarcinoma, and primary gastric lymphoma. Elimination of the infection results in healing of gastritis and cure of peptic ulcer disease.

Recognizing peptic ulcer disease. Keys to clinical and laboratory diagnosis.

An algorithmic approach to evaluation of dyspepsia or abdominal discomfort begins with differentiation between peptic ulcer disease and gastroesophageal reflux disease as well as recognition of alarm signs and symptoms for gastric cancer, which are indications for early endoscopy. In the absence of alarm symptoms, most patients should undergo noninvasive testing for H pylori infection with a serologic, urea breath, or stool antigen test. Factors to consider in selection of appropriate testing include reliability, specificity, sensitivity, cost, and local access and expertise. As a general rule, physicians should choose a test that has the best accuracy for the level of testing expertise available. The basic principle underlying testing for H pylori is that patients should not undergo testing unless the physician is willing to treat on the basis of a positive test result. In patients who receive treatment, confirmation of cure is important for preventing further morbidity and reducing risk of transmission of infection.

Practical advice on eradicating Helicobacter pylori infection.

Peptic ulcer disease associated with H pylori infection is curable. The important factors in selecting therapy are efficacy of eradication, prevention of resistance, avoidance or minimization of adverse effects, patient compliance, and cost. The most effective regimens include a bismuth preparation or antisecretory drug (proton pump inhibitor or H2 receptor antagonist) plus two antibiotics administered for 14 days. Dual-drug therapies are not recommended. Triple-drug regimens are more likely to eradicate H pylori and less likely to generate resistant strains among surviving organisms. In general, cure of the infection should be confirmed 4 weeks after completion of the treatment. Antibiotic resistance is an important consideration in choosing therapy, and patients should be taught the importance of compliance. When treatment fails, antibiotic combinations should not be repeated. Considerations for anti-H pylori treatment in a managed care environment mirror those for good medical practice in general, with special attention to stringent cost-control or outcomes-driven measures.

Insomnia: concerns of the family physician.

Insomnia is frequently seen in the primary care setting. Although poor sleep can impair daytime functioning and directly affect quality of life, insomnia often goes untreated, resulting in perpetuation and, sometimes, exacerbation of the problem. Reversing this trend requires that family physicians become attuned to complaints of insomnia and respond appropriately. Through education about proper sleep hygiene and stress management, and with the appropriate use of hypnotic agents, most cases of insomnia can be managed effectively by the primary care physician and patient without referral to a sleep specialist.

Use of antiplatelet medication for prevention of myocardial infarction and stroke.

Patients who suffer a heart attack can reduce the risk of another attack by 20% by taking 325 mg aspirin daily or every other day. The risk of stroke can be reduced by 50% in patients who experience atrial fibrillation or transient ischemic attacks. Although the benefit of aspirin use in women is controversial, data that suggest that women benefit as well as men are emerging. Antiplatelet drugs should be used only as adjunctive therapy and should not divert one's attention from the more important task of reducing major risk factors, such as smoking, hypertension.

Success strategies for departments of family medicine.

Strong departments of family medicine in academic medical centers help assure the future scope and quality of family practice patient care, the ongoing evolution of family medicine as a scholarly discipline, and a continued flow of qualified medical school graduates into family practice residency programs and eventually into practice. This report presents key strategies of six successful departments of family medicine and describes the methods and skills considered important by the leaders of these departments. Common themes that emerge are (1) recruit and mentor the best faculty, (2) build a reputation for clinical excellence of faculty and residents, (3) become part of schoolwide curriculum activities, (4) establish a scholarly presence, and (5) develop networks of support.

Long-term buspirone therapy for chronic anxiety: a multicenter international study to determine safety.

This report presents results from an international multicenter trial of the safety of buspirone in the treatment of anxiety disorders for periods up to one year, if needed; 424 patients were treated for six months, and 264 patients completed a full year of treatment. Chronic use of buspirone for up to 52 weeks was associated with emergence of no new or unexpected side effects that were not previously reported during shorter periods of treatment. Most patients were successfully managed on daily doses ranging from 15 to 30 mg/day. When buspirone therapy was abruptly discontinued after more than six months of therapy, assessments of patients yielded no evidence of a withdrawal syndrome or unusual events. Although long-term anxiolytic drug therapy is not generally recommended, this open study provides evidence of the potential usefulness of buspirone when used for up to one year. As a general guideline, when an anxiolytic agent is used for several months or longer to treat chronic anxiety, the need for drug therapy should be reevaluated periodically.

Academic promotion and tenure in U.S. family medicine units.

The authors interviewed by telephone the heads (or their representatives) of 101 of the 120 family practice units in U.S. medical schools in 1987. Each respondent was asked for his or her personal perceptions of the relative importances of research, teaching, patient care, and administrative activities in the academic promotion process. Respondents were also asked for their views of their units' and institutions' perceptions of the importances of the same four activities in the promotion process, as well as other related questions about promotion and tenure. The findings indicate that there is still a significant incongruence between the value structure of most family practice units and that of their institutions but that many family practice units are beginning to achieve parity of promotion and tenure with other departments in their institutions.

Assessing the efficacy of antianxiety agents.

Proper evaluation of anxiolytic therapy, involving the possible use of rating scales as well as the physician's skill in observation and communication, is essential in identifying the most appropriate treatment for a given patient and facilitating the management of therapy. These issues are discussed herein, using the clinical trials of buspirone, a new, nonsedating antianxiety agent, as a model for the process of drug selection.

Antihypertensive therapy and quality of life.

Treatment of mild hypertension is becoming increasingly accepted, and many more patients are receiving antihypertensive drugs. A number of new agents offer potential benefits over traditional therapy. These benefits are due to differences in side effect profiles, which have the potential for improved compliance. Quality of life is an important consideration in the selection of antihypertensive therapy.