TREATMENT OF HEPATITIS C .THROUGH VACCINATION ,PROPHYLACTIC TREATMENT

Vaccines for Hepatitis A & B

You may have a family member who has viral hepatitis. Or perhaps you recently saw a news brief about a celebrity who contracted hepatitis A or B. Whatever the reason, you want information about a viral illness that you may not have thought much about. What is viral hepatitis? Are you at risk for it? Do you need viral hepatitis vaccines?

Hepatitis A and B: Diseases of the Liver

Hepatitis is an inflammation of the liver, most often caused by a viral infection. There are three common types of hepatitis caused by viruses: hepatitis A, hepatitis B, and hepatitis C. Vaccines have been developed that protect people from contracting hepatitis A and B. There is no vaccine for hepatitis C.
Hepatitis A and hepatitis B can be spread from person to person, although in different ways. They have similar symptoms, which include abdominal pain, fever, fatigue, joint pain, and jaundice (yellowing of the skin and whites of the eyes).
Over the last 20 years, there has been a 90% decrease in cases of hepatitis A and an 80% decrease in hepatitis B cases in the U.S. Health experts believe that immunization efforts have led to this drop in rates of infection.

How Hepatitis Is Spread

Hepatitis A: About 20,000 people in the U.S. contract hepatitis A each year. The hepatitis A virus is found in the stool of the infected person. It is spread through contaminated food or water or by certain types of sexual contact.
Children who get hepatitis A often don't have symptoms, so they can have the virus and not know it. However, they can still spread it easily. Fortunately, children are now routinely vaccinated against hepatitis A.  
Most people who get hepatitis A recover completely within two weeks to six months and don't have any liver damage. In rare cases, hepatitis A can cause liver failure and even death in older adults or people with underlying liver disease.
 
Hepatitis B: Every year, about 40,000 people in the U.S. become infected with hepatitis B. Acute hepatitis lasts from a few weeks to several months. Many infected people are able to clear the virus and remain virus-free after the acute stage. However, for others, the virus remains in the body, and they develop chronic hepatitis B infection, which is a serious, lifelong condition. About 1.2 million people in the U.S. have chronic hepatitis B. Of these, 15% to 25% will develop more serious health problems, such as liver damage, cirrhosis, liver failure, and liver cancer, and some people die as a result of hepatitis B-related disease.
Hepatitis B can be spread from one person to another from the blood, semen, or other body fluids of an infected person. In the U.S., sexual contact is the most common way that hepatitis B is spread. It can also be spread by sharing needles or other equipment used to inject drugs. In addition, a mother can pass hepatitis B to her baby during birth.
Hepatitis B cannot be spread by contaminated water, food, cooking, or eating utensils, or by breastfeeding, coughing, sneezing, or close contact such as kissing and hugging.

Vaccines for Hepatitis A & B

Who Should Get Hepatitis Vaccinations? continued...

People at risk for hepatitis B include:

• Anyone traveling to or working in areas where hepatitis B is more widespread.
• Health care workers and other people whose job exposes them to human blood
• People with HIV infection, end-stage kidney disease, or chronic liver disease
• People who live with someone with hepatitis B
• People who inject street drugs
• Sexually active people who have had more than one partner
• Anyone who has had an STD
• Men who have sex with men
• Sex partners of people with hepatitis B

Poland also recommends that the parents and siblings of children adopted from a country where hepatitis A and/or hepatitis B are prevalent also receive these hepatitis vaccinations.

Safety of Hepatitis Vaccines

Hepatitis vaccines have been given to millions of people all across the world without any evidence of serious side effects. "They're very safe, and they're extremely effective," says Poland.
If you are not sure whether you should have hepatitis vaccines, talk with your doctor about your specific concerns.

Vaccines for Hepatitis A & B

Vaccines for Hepatitis A and B

Our immune system battles foreign invaders every day, such as when we get a cold virus. When this happens, we develop immunity to that specific virus. This means that our body will fight off the virus if it is ever exposed to it again.
The same protection happens with vaccines. However, the benefit of a vaccination is that you don't have to go through being sick to enable your body to fight off disease.
Gregory Poland, MD, director of the Mayo Clinic's Vaccine Research Group, explains that hepatitis vaccinations contain a small amount of the inactive virus. When you get a dose of the vaccine, he says, your immune cells respond by developing immunity against the virus. This immunity lasts over a long period of time.
"So if I get these two doses of hepatitis A vaccine, and then I get exposed 30 years from now, my body will remember that immunity to the vaccine and rapidly start producing antibodies again," says Poland.
Due to the way hepatitis vaccinations are developed, it is impossible to contract the virus from the vaccine itself, according to Poland.
The hepatitis A vaccine is usually given in two shots and the hepatitis B vaccine is administered as a series of three shots. The most common side effects are redness, pain, and tenderness where the shots are given.
To get long-term protection from these viruses, it's important to receive all the shots as scheduled. However, if you received one shot and never went back for the others, it's not too late to catch up.
"No matter how long the lapse is between doses, you never have to start the series again," says Poland. "You just take off where you left off. So even if someone got their first dose five years ago, we start with the second dose."

Who Should Get Hepatitis Vaccinations?

Since the vaccines were first developed, the hepatitis A and B vaccines have become part of the regular childhood immunization schedule. They are not considered a routine adult immunization.
"When we're talking about adults, I would say yes, get the vaccine if they fit into one of these risk factors" says Poland. "If they don't fit into the risk factors, their risk is so low that there's no compelling reason to do it."
People at risk for hepatitis A include:

• Anyone traveling to or working in areas where hepatitis A is more widespread.
• People whose work puts them in potential contact with hepatitis A, such as those who work with the hepatitis A virus in research labs
• People who are treated with clotting-factor concentrates
• People who have chronic liver disease
• People who use recreational (street) drugs, injected or not
• Men who have sex with men  

Cough Relief: How to Lose a Bad Cough

WAYS TO MITIGATE COUGH

Immunity as You Age

Q: Do we get sick less often as we get older because we’ve been exposed to everything? A: When it comes to infectious diseases, this is largely TRUE. Once we endure the sniffles, coughs, and flu bugs of childhood and adolescence, most of us can expect to be "under the weather" a lot less as adults. "If you’re an adult, you’ve probably had most of the childhood diseases already and have an acquired immunity, so your resistance is a little higher," says Russell Robertson, MD, chair...

“Even a little cough can be debilitating,” says Mark Yoder, MD, assistant professor of pulmonary and critical care medicine at Rush University Medical Center in Chicago.

Cold and flu season brings on hacking coughs that can leave your chest aching. But colds and flu aren’t the only problems that cause coughing. Allergies, asthma, acid reflux, dry air, and smoking are common causes of coughs. Even medications such as certain drugs for high blood pressure and allergies can cause chronic cough.

Most of the time, people can manage their coughs at home by taking over-the-counter medicine and cough lozenges, removing potential allergens, or even just standing in a steamy shower, says Giselle Mosnaim, an allergist and immunologist also at Rush.

Try these five tips to manage your cough at home:

1. Stay Hydrated

An upper respiratory tract infection like a cold or flu causes postnasal drip. Extra secretions trickle down the back of your throat, irritating it and sometimes causing a cough, Mosnaim says. 

Drinking fluids helps to thin out the mucus in postnasal drip, says Kenneth DeVault, MD, professor of medicine at the Mayo Clinic in Jacksonville, Fla. 

Drinking liquids also helps to keep mucous membranes moist. This is particularly helpful in winter, when houses tend to be dry, another cause of cough, he says.

2. Try Lozenges and Hot Drinks

Try a menthol cough drop, Yoder suggests. “It numbs the back of the throat, and that will tend to decrease the cough reflex.”

Drinking warm tea with honey also can soothe the throat. There is some clinical evidence to support this strategy, Yoder says. 

3. Take Steamy Showers, and Use a Humidifier

A hot shower can help a cough by loosening secretions in the nose. Mosnaim says this steamy strategy can help ease coughs not only from colds, but also from allergies and asthma.  

Humidifiers may also help. In a dry home, nasal secretions (snot) can become dried out and uncomfortable, Mosnaim explains. Putting moisture back in the air can help your cough. But be careful not to overdo it.

“The downside is, if you don’t clean it, (humidifiers) become reservoirs for pumping out fungus and mold into the air, and bacteria,” says Robert Naclerio, MD, chief of otolaryngology at the University of Chicago.

4. Remove Irritants From the Air

Perfumes and scented bathroom sprays may seem benign. But for some people they can cause chronic sinus irritation, producing extra mucus that leads to chronic cough, says Alan Weiss, MD, a general internist at the Cleveland Clinic. Take control by avoiding such scented products. 

The worst irritant in the air is, of course, smoke. Almost all smokers eventually develop “smoker’s cough." Everyone around the smoker may suffer from some airway irritation. The best solution? Smokers need to stop smoking. (Yoder warns that severe chronic cough can be a sign of emphysema or lung cancer in smokers, so see a doctor if you’re a smoker with chronic cough.)  

5. Take Medications to Treat Coughs

When steamy showers, hot teas, and cough drops don’t help, you can turn to over-the-counter medicines to ease your cough.

Decongestants: Decongestants relieve nasal congestion by shrinking swollen nasal tissue and reducing mucus production. They dry up mucus in the lungs and open up the airway passages, Weiss says. 

Decongestants come in pills, liquids, and nasal sprays under many brand names. Look for phenylephrine and pseudoephedrine as the active ingredient in decongestants taken by mouth, but be careful. These medicines can raise blood pressure, so people with hypertension need to be careful with their use. Also, overuse of decongestants can lead to excessive dryness, which can trigger a dry cough.

Decongestant nasal sprays, if used for more than 3 or 4 days, can lead to rebound congestion, Mosnaim says. It’s best to use them for 2 or 3 days and then stop.  

Cough suppressantsand expectorants: If you’re coughing so much that your chest hurts and you’re getting a bad night’s sleep, consider a cough suppressant such as dextromethorphan, Mosnaim says. Yoder recommends using cough suppressants only at night.  

When a person has a cough that is thick with phlegm, Mosnaim says it helps to take a cough expectorant such as guaifenesin. Expectorants thin out the mucus so one can more easily cough it up, she says. 

Note: The FDA advises against giving cold and cough medicine to children under age 4. These common over-the-counter drugs can cause serious side effects in young children.

Find Out What’s Causing Your Cough

Coughs caused by the common cold usually go away in a few weeks. Chronic, persistent coughs may be caused by underlying medical problem such as allergies, asthma, or acid reflux -- or by the medications you take. To lose those coughs, you need to treat the underlying problem.

Talk to your doctor if your cough lasts longer than 4 weeks, or if you are coughing up blood or having other symptoms such as weight loss, chills, or fatigue.

TREATMENT PATTERN OF CONSTIPATION

Constipation facts

• Constipation is defined medically as fewer than three stools per week and severe constipation as less than one stool per week.
• Constipation usually is caused by the slow movement of stool through the colon.
• There are many causes of constipation including medications, poor bowel habits, low fiber diets, abuse of laxatives, hormonal disorders, and diseases primarily of other parts of the body that also affect the colon.
• The two disorders limited to the colon that cause constipation are colonic inertia and pelvic floor dysfunction.
• High levels of estrogen and progesterone during pregnancy also can cause constipation.
• Medical evaluation for the cause of constipation should be done when constipation is of sudden onset, severe, worsening, associated with other worrisome symptoms such as loss of weight, or is not responding to simple, safe treatments.
• Medical evaluation of constipation may include a history, physical examination, blood tests, abdominal X-rays, barium enema, colonic transit studies, defecography, anorectal motility studies, and colonic motility studies.
• The goal of therapy for constipation is one bowel movement every two to three days without straining.
• Treatment of constipation may include dietary fiber, non-stimulant laxatives, stimulant laxatives, enemas, suppositories, biofeedback training, and surgery.
• Stimulant laxatives should be used as a last resort because of the possibility that they may permanently damage the colon and worsen constipation.
• Most herbal laxatives contain stimulant-type laxatives and should be used, if at all, as a last resort.

What is constipation?

Constipation means different things to different people. For many people, it simply means infrequent stools. For others, however, constipation means hard stools, difficulty passing stools (straining), or a sense of incomplete emptying after a bowel movement. The cause of each of these "types" of constipation probably is different, and the approach to each should be tailored to the specific type of constipation.
Constipation also can alternate with diarrhea. This pattern commonly occurs as part of the irritable bowel syndrome (IBS). At the extreme end of the constipation spectrum is fecal impaction, a condition in which stool hardens in the rectum and prevents the passage of any stool.
The number of bowel movements generally decreases with age. Ninety-five percent of adults have bowel movements between three and 21 times per week, and this would be considered normal. The most common pattern is one bowel movement a day, but this pattern is seen in less than 50% of people. Moreover, most people are irregular and do not have bowel movements every day or the same number of bowel movements each day.
Medically speaking, constipation usually is defined as fewer than three bowel movements per week. Severe constipation is defined as less than one bowel movement per week. There is no medical reason to have a bowel movement every day. Going without a bowel movement for two or three days does not cause physical discomfort, only mental distress for some people. Contrary to popular belief, there is no evidence that "toxins" accumulate when bowel movements are infrequent or that constipation leads to cancer.
It is important to distinguish acute (recent onset) constipation from chronic (long duration) constipation. Acute constipation requires urgent assessment because a serious medical illness may be the underlying cause (for example, tumors of the colon). Constipation also requires an immediate assessment if it is accompanied by worrisome symptoms such as rectal bleeding, abdominal pain and cramps, nausea and vomiting, and involuntary loss of weight. In contrast, the evaluation of chronic constipation may not be urgent, particularly if simple measures bring relief.

What's new in the treatment of constipation?

Each part of the intestine (stomach, small intestine, and colon) has a network of nerves that controls its muscles. A great deal of research is being done in order to gain an understanding of how these nerves control each other and ultimately the muscles. Much of this research involves the study of neurotransmitters. (Neurotransmitters are chemicals that nerves use to communicate with each other.) This research is allowing scientists to develop drugs that stimulate (and inhibit) the various nerves of the colon which, in turn, cause the muscles of the colon to contract and propel the colonic contents. Such drugs have great potential for the treatment of constipation that is due to colonic inertia. The first of these drugs is in clinical trials and is likely to be available soon. These drugs are an exciting development because they offer a new treatment for a difficult-to-treat form of constipation.
Nevertheless, there are many questions about these types of drugs that must be answered. How effective are they? Will they work in many or only a few patients? Will they work in patients who have damaged their nerves with stimulant laxatives? Since these medications are likely to be used for a lifetime, how safe will they be with many years of use? Will they be used indiscriminately in situations for which simple treatments (for example, fiber) or more appropriate treatments (for example, biofeedback training) should be used?

TREATMENT OF PILES

Piles (haemorrhoids) often go away by themselves after a few days. However, there are many treatments that can reduce itching and discomfort.
Making simple dietary changes and not straining on the toilet are often recommended first.
If more invasive treatment is needed, the type of treatment used will depend on where your haemorrhoids are, particularly if they have developed above, on or below the dentate line. This is a line in the anal canal that separates the areas where the nerves can and can't transmit pain messages.
Non-surgical treatments are likely to be very painful for haemorrhoids that have developed on or below the dentate line, as the nerves in this area can detect pain. In these cases, haemorrhoid surgery will normally be recommended.

Dietary changes and self-care

If constipation is thought to be the cause of your haemorrhoids, you need to keep your stools soft and regular, so that you don't strain when passing stools.
You can do this by increasing the amount of fibre in your diet. Good sources of fibre include wholegrain bread, cereal, fruit and vegetables. Read more about preventing constipation.
You should also drink plenty of water and avoid caffeine (found in tea, coffee and cola).
Follow the below advice when going to the toilet:

• avoid straining to pass stools, as this may make your haemorrhoids worse
• after passing a stool, use moist toilet paper or baby wipes to clean your bottom, rather than dry toilet paper
• pat the area around your bottom, rather than rubbing it

Medication

Over-the-counter topical treatments

Various creams, ointments and suppositories (which are inserted into your bottom) are available from pharmacies without a prescription. They can be used to relieve any swelling and discomfort.
These medicines should only be used for five to seven days at a time. If you use them for longer, they may irritate the sensitive skin around your anus. Any medication should be combined with the diet and self-care advice detailed above.
There is no evidence that one method is more effective than another. Ask your pharmacist for advice about which product is most suitable for you. Always read the patient information leaflet that comes with your medicine before using it.
Do not use more than one product at the same time.

Corticosteroid cream

If you have severe inflammation in and around your back passage, your GP may prescribe corticosteroid cream, which contains steroids.
You should not use corticosteroid cream for more than a week at a time, as it can make the skin around your anus thinner and the irritation worse.

Painkillers

Common painkilling medication, such as paracetamol, can relieve the pain of haemorrhoids. However, you should avoid codeine painkillers, as they can cause constipation.
Products that contain local anaesthetic (painkilling medication) may also be prescribed by your GP to treat painful haemorrhoids. Like over-the-counter topical treatments, these should only be used for a few days, as they can make the skin around your back passage more sensitive.

Laxatives

If you are constipated, your GP may prescribe a laxative. This is a type of medication that can help you empty your bowels.

Non-surgical treatments

If dietary changes and medication don't help, your GP may refer you to a specialist. They can confirm whether you have haemorrhoids and recommend appropriate treatment.
If your haemorrhoids are found to have developed above the dentate line, non-surgical procedures such as banding and sclerotherapy may be recommended.

Banding

Banding is a procedure that involves placing a very tight elastic band around the base of your haemorrhoids, to cut off their blood supply. The haemorrhoids should then fall off within about a week of having the treatment.
Banding is usually a day procedure, without the need for an anaesthetic, and most people can return to their normal activities the next day. You may feel some pain or discomfort for a day or so. Normal painkillers are usually effective, but your GP can prescribe something stronger, if needed.
You may not realise that your haemorrhoids have fallen off, as they should pass out of your body when you go to the toilet. If you notice some mucus discharge within a week of the procedure, it usually means the haemorrhoid has fallen off.
Directly after the procedure, you may notice blood on the toilet paper after going to the toilet. This is normal, but there should not be a lot of bleeding. If you pass a lot of bright red blood or blood clots (solid lumps of blood), go to your nearest accident and emergency (A&E) department immediately.
Ulcers (open sores) can occur at the site of the banding, although these usually heal without needing treatment.

Injections (sclerotherapy)

A treatment called sclerotherapy may be used as an alternative to banding.
During sclerotherapy, a chemical solution is injected into the blood vessels in your back passage. This relieves pain by numbing the nerve endings at the site of the injection. It also hardens the tissue of the haemorrhoid so that a scar is formed. After about four to six weeks, the haemorrhoid should decrease in size or shrivel up.
After the injection, avoid strenuous exercise for the rest of the day. You may experience minor pain for a while and may bleed a little. You should be able to resume normal activities, including work, the day after the procedure.

Infrared coagulation

Infrared coagulation is also sometimes used to treat haemorrhoids.
During the procedure, a special device that emits infrared light is used to burn the haemorrhoid tissue and cut off their blood supply.
A similar procedure can also be carried out using an electric current instead of infrared light. This is known as diathermy or electrotherapy.

Surgery

Although most haemorrhoids can be treated using the methods described above, around 1 in every 10 people with the condition will eventually need surgery.
Surgery is particularly useful for haemorrhoids that have developed below the dentate line because, unlike non-surgical treatments, anaesthetic is used to ensure you don’t feel any pain as they are carried out.
There are many different types of surgery that can be used for haemorrhoids, but they usually involve either removing the haemorrhoids or reducing their blood supply, causing them to shrink.

Treatment for Diabetes

What is the treatment for diabetes?

 

The major goal in treating diabetes is to minimize any elevation of blood sugar (glucose) without causing abnormally low levels of blood sugar. Type 1 diabetes is treated with insulin, exercise, and a diabetic diet. Type 2 diabetes is treated first with weight reduction, a diabetic diet, and exercise. When these measures fail to control the elevated blood sugars, oral medications are used. If oral medications are still insufficient, treatment with insulin is considered.
Adherence to a diabetic diet is an important aspect of controlling elevated blood sugar in patients with diabetes. The American Diabetes Association (ADA) has provided guidelines for a diabetic diet. The ADA diet is a balanced, nutritious diet that is low in fat, cholesterol, and simple sugars. The total daily calories are evenly divided into three meals. In the past two years, the ADA has lifted the absolute ban on simple sugars. Small amounts of simple sugars are allowed when consumed with a complex meal.
Weight reduction and exercise are important treatments for diabetes. Weight reduction and exercise increase the body's sensitivity to insulin, thus helping to control blood sugar elevations.

Medications for type 2 diabetes

WARNING: All the information below applies to patients who are not pregnant or breastfeeding. At present the only recommended way of controlling diabetes in women who are pregnant or breastfeeding is by diet, exercise and insulin therapy. You should speak with your doctor if you are taking these medications and are considering becoming pregnant or if you have become pregnant while taking these medications.
Based on what is known, medications for type 2 diabetes are designed to:

1. increase the insulin output by the pancreas,
2. decrease the amount of glucose released from the liver,
3. increase the sensitivity (response) of cells to insulin,
4. decrease the absorption of carbohydrates from the intestine, and
5. slow emptying of the stomach to delay the presentation of carbohydrates for digestion and absorption in the small intestine.

When selecting therapy for type 2 diabetes, consideration should be given to:

1. the magnitude of change in blood sugar control that each medication will provide;
2. other coexisting medical conditions (high blood pressure, high cholesterol, etc.);
3. adverse effects of the therapy;
4. contraindications to therapy;
5. issues that may affect compliance (timing of medication, frequency of dosing); and
6. cost to the patient and the health care system.

It's important to remember that if a drug can provide more than one benefit (lower blood sugar and have a beneficial effect on cholesterol, for example), it should be preferred. It's also important to bear in mind that the cost of drug therapy is relatively small compared to the cost of managing the long-term complications associated with poorly controlled diabetes.
Varying combinations of medications also are used to correct abnormally elevated levels of blood glucose in diabetes. As the list of medications continues to expand, treatment options for type 2 diabetes can be better tailored to meet an individuals needs. Not every patient with type 2 diabetes will benefit from every drug, and not every drug is suitable for each patient. Patients with type 2 diabetes should work closely with their physicians to achieve an approach that provides the greatest benefits while minimizing risks.
Patients with diabetes should never forget the importance of diet and exercise. The control of diabetes starts with a healthy lifestyle regardless of what medications are being used.

Premature Ejaculation - Topic Overview,TREATMENT PROTOCOL

What is premature ejaculation?

 

Premature ejaculation is uncontrolled ejaculation either before or shortly after sexual penetration, with minimal sexual stimulation and before the person wishes. It may result in an unsatisfactory sexual experience for both partners. This can increase the anxiety that may contribute to the problem. Premature ejaculation is one of the most common forms of male sexual dysfunction and has probably affected every man at some point in his life.

What causes premature ejaculation?

Most cases of premature ejaculation do not have a clear cause. With sexual experience and age, men often learn to delay orgasm. Premature ejaculation may occur with a new partner, only in certain sexual situations, or if it has been a long time since the last ejaculation. Psychological factors such as anxiety, guilt, or depression can cause premature ejaculation. In some cases, premature ejaculation may be related to a medical cause such as hormonal problems, injury, or a side effect of certain medicines.

What are the symptoms?

The main symptom of premature ejaculation is an uncontrolled ejaculation either before or shortly after intercourse begins. Ejaculation occurs before the person wishes it, with minimal sexual stimulation.

How is premature ejaculation diagnosed?

Your doctor will discuss your medical and sexual history with you and conduct a thorough physical exam. Your doctor may want to talk to your partner also. Premature ejaculation can have many causes. So your doctor may order laboratory tests to rule out any other medical problem.

How is it treated?

In many cases premature ejaculation resolves on its own over time without the need for medical treatment. Practicing relaxation techniques or using distraction methods may help you delay ejaculation. For some men, stopping or cutting down on the use of alcohol, tobacco, or illegal drugs may improve their ability to control ejaculation.
Your doctor may recommend that you and your partner practice specific techniques to help delay ejaculation. These techniques may involve identifying and controlling the sensations that lead up to ejaculation and communicating to slow or stop stimulation. Other options include using a condom to reduce sensation to the penis or trying a different position (such as lying on your back) during intercourse. Counseling or behavioral therapy may help reduce anxiety related to premature ejaculation.
Antidepressant medicines such as clomipramine (Anafranil) and dapoxetine (Priligy) are sometimes used to treat premature ejaculation. These medicines are used because one of their side effects is inhibited orgasm, which helps delay ejaculation. Tramadol (Ultram), which has been used for many years to control pain, is another medicine that can delay ejaculation.
There are also creams, gels, and a spray that may be used to treat premature ejaculation by reducing sensation. These medicines, such as lidocaine or lidocaine-prilocaine, are applied to the penis before sexual intercourse. But some of these medicines can also affect a man's sexual partner by reducing sensation for the partner.

TREATMENT OF CANCER, HOW ARE DOCTORS TRAINED

1. How are doctors trained and certified to treat cancer patients?

   When choosing a doctor for your cancer care, you may find it helpful to know some of the terms used to describe a doctor’s training and credentials. Most physicians who treat people with cancer are medical doctors (they have an M.D. degree) or osteopathic doctors (they have a D.O. degree). The basic training for both types of physicians includes 4 years of premedical education at a college or university, 4 years of medical school to earn an M.D. or D.O. degree, and postgraduate medical education through internships and residences. This training usually lasts 3 to 7 years. Physicians must pass an exam to become licensed (legally permitted) to practice medicine in their state. Each state or territory has its own procedures and general standards for licensing physicians.
   Specialists are physicians who have completed their residency training in a specific area, such as internal medicine. Independent specialty boards certify physicians after they have fulfilled certain requirements. These requirements include meeting specific education and training criteria, being licensed to practice medicine, and passing an examination given by the specialty board. Doctors who have met all of the requirements are given the status of “Diplomate” and are board certified as specialists. Doctors who are board eligible have obtained the required education and training but have not completed the specialty board examination.
   After being trained and certified as a specialist, a physician may choose to become a subspecialist. A subspecialist has at least 1 additional year of full-time education in a particular area of a specialty. This training is designed to increase the physician’s expertise in a specific field. Specialists can be board certified in their subspecialty as well.
   The following are some specialties and subspecialties that pertain to cancer treatment:
   
   • Medical Oncology is a subspecialty of internal medicine. Doctors who specialize in internal medicine treat a wide range of medical problems. Medical oncologists treat cancer and manage the patient’s course of treatment. A medical oncologist may also consult with other physicians about the patient’s care or refer the patient to other specialists.
   • Hematology is a subspecialty of internal medicine. Hematologists focus on diseases of the blood and related tissues, including the bone marrow, spleen, and lymph nodes.
   • Radiation Oncology is a subspecialty of radiology. Radiology is the use of x-rays and other forms of radiation to diagnose and treat disease. Radiation oncologists specialize in the use of radiation to treat cancer.
   • Surgery is a specialty that pertains to the treatment of disease by surgical operation. General surgeons perform operations on almost any area of the body. Physicians can also choose to specialize in a certain type of surgery; for example, thoracic surgeons are specialists who perform operations specifically in the chest area, including the lungs and the esophagus.
   The American Board of Medical Specialties® (ABMS) is a not-for-profit organization that assists medical specialty boards with the development and use of standards for evaluation and certification of physicians. Information about other specialties that treat cancer is available from the ABMS website .
   Almost all board-certified specialists are members of their medical specialty society. Physicians can attain Fellowship status in a specialty society, such as the American College of Surgeons (ACS), if they demonstrate outstanding achievement in their profession. Criteria for Fellowship status may include the number of years of membership in the specialty society, years practicing in the specialty, and professional recognition by peers.

2. How can I find a doctor who specializes in cancer care?

   One way to find a doctor who specializes in cancer care is to ask for a referral from your primary care physician. You may know a specialist yourself, or through the experience of a family member, coworker, or friend.
   The following resources may also be able to provide you with names of doctors who specialize in treating specific diseases or conditions. However, these resources may not have information about the quality of care that the doctors provide.
   
   • Your local hospital or its patient referral service may be able to provide you with a list of specialists who practice at that hospital.
   • Your nearest NCI-designated cancer center can provide information about doctors who practice at that center. The NCI-Designated Cancer Centers Find a Cancer Center page provides contact information to help health care providers and cancer patients with referrals to NCI-designated cancer centers located throughout the United States.
   • The ABMS has a list of doctors who have met certain education and training requirements and have passed specialty examinations. Is Your Doctor Board Certified lists doctors’ names along with their specialty and their educational background. Users must register to use this online self-serve resource, which allows users to conduct searches by a physician's name or area of certification and a state name. The directory is available in most libraries.
   • The American Medical Association (AMA) DoctorFinder database provides basic information on licensed physicians in the United States. Users can search for physicians by name or by medical specialty.
   • The American Society of Clinical Oncology (ASCO) provides an online list of doctors who are members of ASCO. The member database has the names and affiliations of nearly 30,000 oncologists worldwide. It can be searched by doctor’s name, institution, location, oncology specialty, and/or type of board certification.
   • The American College of Surgeons (ACS) membership database is an online list of surgeons who are members of the ACS. The list can be searched by doctor’s name, geographic location, or medical specialty. The ACS can be contacted by telephone at 1–800–621–4111.
   • The American Osteopathic Association (AOA) Find a Doctor database provides an online list of practicing osteopathic physicians who are AOA members. The information can be searched by doctor’s name, geographic location, or medical specialty. The AOA can be contacted by telephone at 1–800–621–1773.
   • Local medical societies may maintain lists of doctors in each specialty.
   • Public and medical libraries may have print directories of doctors’ names listed geographically by specialty.
   • Your local Yellow Pages or Yellow Book may have doctors listed by specialty under “Physicians.”
   If you are a member of a health insurance plan, your choice may be limited to doctors who participate in your plan. Your insurance company can provide you with a list of participating primary care doctors and specialists. It is important to ask whether the doctor you are considering is accepting new patients through your health plan. You also have the option of seeing a doctor outside your health plan and paying the costs yourself. If you have the option to change health insurance plans, you may first wish to consider which doctor or doctors you would like to use, and then choose a plan that includes your chosen physician(s).
   If you are using a federal or state health insurance program such as Medicare or Medicaid, you may want to ask whether the doctor you are considering is accepting patients who use these programs.
   You will have many factors to consider when choosing a doctor. To make an informed decision, you may wish to speak with several doctors before choosing one. When you meet with each doctor, you might want to consider the following:
   
   • Does the doctor have the education and training to meet my needs?
   • Does the doctor use the hospital that I have chosen?
   • Does the doctor listen to me and treat me with respect?
   • Does the doctor explain things clearly and encourage me to ask questions?
   • What are the doctor’s office hours?
   • Who covers for the doctor when he or she is unavailable? Will that person have access to my medical records?
   • How long does it take to get an appointment with the doctor?
   If you are choosing a surgeon, you may wish to ask additional questions about the surgeon’s background and experience with specific procedures. These questions may include:
   
   • Is the surgeon board certified?
   • Has the surgeon been evaluated by a national professional association of surgeons, such as the ACS?
   • At which treatment facility or facilities does the surgeon practice?
   • How often does the surgeon perform the type of surgery I need?
   • How many of these procedures has the surgeon performed? What was the success rate?
   It is important for you to feel comfortable with the specialist that you choose because you will be working closely with that person to make decisions about your cancer treatment. Trust your own observations and feelings when deciding on a doctor for your medical care.

3. How can I get another doctor’s opinion about the diagnosis and treatment plan?

   After your doctor gives you advice about the diagnosis and treatment plan, you may want to get another doctor’s opinion before you begin treatment. This is known as getting a second opinion. You can do this by asking another specialist to review all of the materials related to your case. The doctor who gives the second opinion can confirm or suggest modifications to your doctor’s proposed treatment plan, provide reassurance that you have explored all of your options, and answer any questions you may have.
   Getting a second opinion is done frequently, and most physicians welcome another doctor’s views. In fact, your doctor may be able to recommend a specialist for this consultation. However, some people find it uncomfortable to request a second opinion. When discussing this issue with your doctor, it may be helpful to express satisfaction with your doctor’s decision and care and to mention that you want your decision about treatment to be as thoroughly informed as possible. You may also wish to bring a family member along for support when asking for a second opinion. It is best to involve your doctor in the process of getting a second opinion, because your doctor will need to make your medical records (such as your test results and x-rays) available to the specialist who is giving the second opinion.
   Some health care plans require a second opinion, particularly if a doctor recommends surgery. Other health care plans will pay for a second opinion if the patient requests it. If your plan does not cover a second opinion, you can still obtain one if you are willing to cover the cost.
   If your doctor is unable to recommend a specialist for a second opinion, or if you prefer to choose one on your own, the following resources can help:
   
   • Many of the resources listed above for finding a doctor can also help you find a specialist for a consultation.
   • The NIH Clinical Center in Bethesda, Maryland, is the research hospital for the NIH, including NCI. Several branches of the NCI provide second opinion services. The NCI fact sheet Cancer Clinical Trials at the NIH Clinical Center describes these NCI branches and their services.
   • The R. A. Bloch Cancer Foundation, Inc., can refer cancer patients to institutions that are willing to provide multidisciplinary second opinions. A list of these institutions is available on the organization’s website . You can also contact the R. A. Bloch Cancer Foundation, Inc., by telephone at 816–854–5050 or 1–800–433–0464.

4. How can U.S. residents find treatment facilities?

   Choosing a treatment facility is another important consideration for getting the best medical care possible. Although you may not be able to choose which hospital treats you in an emergency, you can choose a facility for scheduled and ongoing care. If you have already found a doctor for your cancer treatment, you may need to choose a facility based on where your doctor practices. Your doctor may be able to recommend a facility that provides quality care to meet your needs. You may wish to ask the following questions when considering a treatment facility:
   
   • Has the facility had experience and success in treating my condition?
   • Has the facility been rated by state, consumer, or other groups for its quality of care?
   • How does the facility check on and work to improve its quality of care?
   • Has the facility been approved by a nationally recognized accrediting body, such as the ACS Commission on Cancer and/or The Joint Commission?
   • Does the facility explain patients’ rights and responsibilities? Are copies of this information available to patients?
   • Does the treatment facility offer support services, such as social workers and resources, to help me find financial assistance if I need it?
   • Is the facility conveniently located?
   If you are a member of a health insurance plan, your choice of treatment facilities may be limited to those that participate in your plan. Your insurance company can provide you with a list of approved facilities. Although the costs of cancer treatment can be very high, you do have the option of paying out-of-pocket if you want to use a treatment facility that is not covered by your insurance plan. If you are considering paying for treatment yourself, you may wish to discuss the possible costs with your doctor beforehand. You may also want to speak with the person who does the billing for the treatment facility. Nurses and social workers may also be able to provide you with more information about coverage, eligibility, and insurance issues.
   The following resources may help you find a hospital or treatment facility for your care:
   
   • The NCI-Designated Cancer Centers Find a Cancer Center page provides contact information for NCI-designated cancer centers located throughout the country.
   • The ACS’s Commission on Cancer (CoC) accredits cancer programs at hospitals and other treatment facilities. More than 1,430 programs in the United States have been designated by the CoC as Approved Cancer Programs. The ACS website offers a searchable database of these programs.
   • The Joint Commission is an independent not-for-profit organization that evaluates and accredits health care organizations and programs in the United States. It also offers information for the general public about choosing a treatment facility. The Joint Commission can be contacted by telephone at 630–792–5000.
   The Joint Commission offers an online Quality Check® service that patients can use to determine whether a specific facility has been accredited by the Joint Commission and to view the organization’s performance reports.

5. How can people who live outside the United States find treatment facilities in or near their countries?

   If you live outside the United States, facilities that offer cancer treatment may be located in or near your country. Cancer information services are available in many countries to provide information and answer questions about cancer; they may also be able to help you find a cancer treatment facility close to where you live. A list of these cancer information services is available on the website of the International Cancer Information Service Group , an independent international organization of cancer information services. A list may also be requested by writing to the NCI Public Inquiries Office at:
   Cancer Information Service
   BG 9609 MSC 9760
   9609 Medical Center Drive
   Bethesda, MD 20892-9760
   USA
   The Union for International Cancer Control (UICC) is another resource for people living outside the United States who want to find a cancer treatment facility. The UICC consists of international cancer-related organizations devoted to the worldwide fight against cancer. UICC membership includes research facilities and treatment centers and, in some countries, ministries of health. Other members include volunteer cancer leagues, associations, and societies. These organizations serve as resources for the public and may have helpful information about cancer and treatment facilities. To find a resource in or near your country, contact the UICC at:
   Union for International Cancer Control (UICC)
   

6. How can people who live outside the United States get a second opinion or have cancer treatment in the United States?

   Some people living outside the United States may wish to obtain a second opinion or have their cancer treatment in this country. Many facilities in the United States offer these services to international cancer patients. These facilities may also provide support services, such as language interpretation, assistance with travel, and guidance in finding accommodations near the treatment facility for patients and their families.
   If you live outside the United States and would like to obtain cancer treatment in this country, you should contact cancer treatment facilities directly to find out whether they have an international patient office. The NCI-Designated Cancer Centers Find a Cancer Center page offers contact information for NCI-designated cancer centers throughout the United States.
   Citizens of other countries who are planning to travel to the United States for cancer treatment generally must first obtain a nonimmigrant visa for medical treatment from the U.S. Embassy or Consulate in their home country. Visa applicants must demonstrate that the purpose of their trip is to enter the United States for medical treatment; that they plan to remain for a specific, limited period; that they have funds to cover expenses in the United States; that they have a residence and social and economic ties outside the United States; and that they intend to return to their home country.
   To determine the specific fees and documentation required for the nonimmigrant visa and to learn more about the application process, contact the U.S. Embassy or Consulate in your home country. A list of links to the websites of U.S. Embassies and Consulates worldwide can be found on the U.S. Department of State’s website.
   More information about nonimmigrant visa services is available on the U.S. Department of State's Temporary Visitors to the U.S. page.

TREATMENT PROTOCOL OF TYPHOID

1. Take Temperature

 

• Temperature can be taken orally, rectally, or under the armpit.

• A person is considered feverish if oral temperature is above 100º F (37.8 C) or rectal temperature is above 100.7º F (38.2 C). Temperatures measured under the armpit are not considered as accurate and can be as much as 1º F lower than an oral measurement.

• A temperature below 100.4º (38 C) is considered a low-grade or mild fever. It means that the body is responding to an infection.

2. Treat Fever, if Necessary

No treatment is necessary for a mild fever unless the person is uncomfortable. If the fever is 102º or higher:

• Give an over-the-counter medicine such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) as directed on the label. Warning: Do NOT give aspirin to anyone age 18 or younger unless directed to do so by a doctor.

• Bathing or sponging in lukewarm water may bring the temperature down. Do not use cold water or alcohol.

• Have the person wear light clothing and use a light cover or sheet -- overdressing can make body temperature go up. If the person gets chills, use an extra blanket until they go away.

3. Give Liquids

• Have the person drink plenty of fluids to stay hydrated.

4. When to Contact a Doctor

Seek medical help immediately if the person has:

• A history of serious illness such as AIDS, heart disease, cancer, or diabetes, or if the person is taking immunosuppressant drugs

• A high fever that doesn't respond to fever-reducing medicine

• Been exposed to extremely hot weather and feels hot but is not sweating

• A stiff neck, is confused, or has trouble staying awake

• Severe pain in the lower abdomen

• Severe stomach pain, vomits repeatedly, or has severe diarrhea

• Skin rashes, blisters, or a red streak on an arm or leg

• A severe sore throat, severe swelling of the throat, or a persistent earache

• Pain with urination, back pain, or shaking chills.

• A severe cough, coughs up blood, or has trouble breathing

5. Follow Up

Contact a doctor if the high body temperature lasts for more than three days or gets worse.

Pharmacological therapy,and Treatment

Pharmacologic Therapy

If lifestyle modifications are insufficient to achieve the goal blood pressure (BP), there are several drug options for the treatment and management of hypertension. Based on the Seventh Report of the Joint National Committee of Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) and the 2010 Institute for Clinical Systems Improvement (ICSI) guideline on the diagnosis and treatment of hypertension recommendations, thiazide diuretics are the preferred initial agents in the absence of compelling indications.^[4] However, the updated JNC 8 guidelines no longer recommend only thiazide-type diuretics as the initial therapy in most patients (angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], calcium channel blockers [CCBs], or diuretics are also good choices).

Compelling indications may include high-risk conditions that can be direct sequelae of hypertension (heart failure, ischemic heart disease, chronic kidney disease, recurrent stroke) or that are commonly associated with hypertension (diabetes, high coronary disease risk), as well as drug intolerability or contraindications.^[4] In such compelling cases, another class of drugs should be initiated. An ACE inhibitor, ARB, CCB, and beta-blocker are all acceptable alternative agents. There are several opinions regarding which antihypertensive agents to use initially, because some patients may respond to a therapy that others may not.

The following are drug class recommendations for compelling indications based on various clinical trials :

• Heart failure: diuretic, beta-blocker, ACE inhibitor, ARB, aldosterone antagonist
• Postmyocardial infarction: beta-blocker, ACE inhibitor, aldosterone antagonist
• High coronary disease risk: diuretic, beta-blocker, ACE inhibitor, CCB
• Diabetes: diuretic, beta-blocker, ACE inhibitor, ARB, CCB
• Chronic kidney disease: ACE inhibitor, ARB
• Recurrent stroke prevention: diuretic, ACE inhibitor

Note that different stages of these diseases may alter their treatment management.

Multiple clinical trials suggest that most antihypertensive drugs provide the same degree of cardiovascular protection for the same level of BP control. Well-designed prospective randomized trials, such as the Swedish Trial in Old Patients with Hypertension (STOP-2), the Nordic Diltiazem (NORDIL) trial, and the Intervention as a Goal in Hypertension Treatment (INSIGHT) trial, have shown that older drugs (eg, diuretics, beta-blockers) and newer antihypertensive agents (eg, ACE inhibitors, CCBs) have similar results.

In addition, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study concluded that there were no differences in primary coronary heart disease outcome or mortality for the thiazide-like diuretic chlorthalidone, the ACE inhibitor lisinopril, and the CCB amlodipine. In a systematic review and meta-analysis, investigators also determined that in patients with essential hypertension without preexisting renal disease, no significant difference was found between Ras inhibitors and other antihypertensive agents in preventing renal dysfunction.

A post hoc analysis of data from the randomized ACCOMPLISH trial concluded that benazepril plus amlodipine (B+A) was more effective than benazepril plus hydrochlorothiazide (B+H) in reducing cardiovascular events in adults with high-risk stage 2 hypertension and coronary artery disease (CAD).

In this study, 5314 patients with CAD and 6192 without CAD were given B+A or B+H. Among patients with CAD, the incidence of cardiovascular events was 16% with B+H and 13% with B+A, a hazard reduction of 18% (P = 0.0016).The composite secondary endpoint of cardiovascular mortality, myocardial infarction, and stroke occurred in significantly fewer B+A patients than B+H patients (5.74% vs 8%; P = 0.033). All-cause mortality was 23% lower in the B+A arm (P = 0.042).

Single agent versus multiagent treatment approach

Over 50% of patients with hypertension will require more than one drug for blood pressure control. In stage 1 hypertension, a single agent is generally sufficient to reduce BP, whereas in stage 2, a multidrug approach may be needed. Initiation of 2 antihypertensive agents, either as 2 separate prescriptions or as a fixed-dose combination, should also be considered when BP is more than 20 mm Hg above the systolic goal (or 10 mm Hg above the diastolic goal).

Several situations demand the addition of a second drug, because 2 drugs may be used at lower doses to avoid the adverse effects that may occur with higher doses of a single agent. Diuretics generally potentiate the effects of other antihypertensive drugs by minimizing volume expansion. Specifically, the use of a thiazide diuretic in conjunction with a beta-blocker or an ACE inhibitor has an additive effect, controlling BP in up to 85% of patients.

The ALTITUDE trial was halted because it was shown that aliskiren can cause adverse events—nonfatal stroke, renal complications, hyperkalemia, and hypotension—when used in combination with an ACE inhibitor or an angiotensin receptor blocker (ARB) in patients with type 2 diabetes and renal impairment who are at high risk of cardiovascular and renal events.

Hypertension treatment and management

RATIONALISING HYPERTENSION

Many guidelines exist for the management of hypertension. Two of the most widely used recommendations are those from the American Diabetes Association (ADA) and the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). The Eighth Report of the JNC (JNC 8) was released in December 2013.^{[10, 11]}

2013 updated JNC 8 guidelines

Two key recommendations in the JNC 8 guidelines that differ from the JNC 7 guidelines are (1) less aggressive targeting of blood pressures (BPs) and treatment-initiation thresholds for elderly patients and for those younger than age 60 years with diabetes and kidney disease and (2) no longer recommending only thiazide-type diuretics as the initial therapy in most patients (angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], calcium channel blockers [CCBs], or diuretics are recommended).

The JNC 8 recommendations include the following

• In patients aged 60 years or older, initiate therapy in those with systolic BP levels at 150 mm Hg or greater or whose diastolic BP levels are 90 mm Hg or greater; treat to below those thresholds
• In patients younger than 60 years as well as those older than 18 years with either chronic kidney disease (CKD) or diabetes, the BP treatment initiation and goals should be 140/90 mm Hg
• In non black hypertensive patients, begin treatment with either a thiazide-type diuretic, CCB, ACE inhibitor, or ARB
• In hypertensive black patients, initiate therapy with a thiazide-type diuretic or CCB
• Regardless of race or diabetes status, in patients 18 years or older with CKD, initial or add-on therapy should consist of an ACE inhibitor or ARB
• Do not use an ACE inhibitor in conjunction with an ARB in the same patient
• If a patient's goal BP is not achieved within 1 month of treatment, increase the dose of the initial agent or add an agent from another of the recommended drug classes; if 2-drug therapy is unsuccessful for reaching the target BP, add a third agent from the recommended drug classes
• In patients whose goal BP cannot be reached with 3 agents from the recommended drug classes, use agents from other drug classes and/or refer the patients to a hypertension specialist

Collaborative AHA/ACC/CDC advisory recommendations

A science advisory on the treatment of hypertension, issued in November 2013 via a collaborative effort by the American Heart Association (AHA), the American College of Cardiology (ACC), and the Centers for Disease Control and Prevention (CDC), describes criteria for successful hypertension management algorithms and advocates the creation of algorithms that can be incorporated into a system-level approach to high BP, as well as modified to accommodate different practice settings and patient populations.^{[58, 59]}

A joint AHA/ACC/CDC algorithm in the report includes the following recommendations^{[58, 59]} :

• BP: Recommended goal of 139/89 mm Hg or less
• Stage 1 hypertension (systolic BP 140-159 mm Hg or diastolic BP 90-99 mm Hg): Can be treated with lifestyle modifications and, if needed, a thiazide diuretic
• Stage 2 hypertension (systolic BP >160 mm Hg or diastolic BP >100 mm Hg): Can be treated with a combination of a thiazide diuretic and an ACE inhibitor, an angiotensin receptor blocker, or a calcium channel blocker
• Patients who fail to achieve BP goals: Medication doses can be increased and/or a drug from a different class can be added to treatment

Joint ESH and ESC guidelines

In June 2013, the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) released new guidelines for the management of hypertension, recommending that all patients, except special populations such as patients with diabetes and the elderly, be treated to below 140 mm Hg systolic BP.^{[8, 9]} The guidelines advise that physicians should make decisions on treatment strategies based on the patient's overall level of cardiovascular risk.

Recommendations of the new ESH and ESC guidelines include^{[8, 9]} :

• In patients younger than 80 years, the systolic BP target should be 140 to 150 mm Hg, but physicians can go lower than 140 mm Hg if the patient is fit and healthy; the same advice applies to octogenarians—however, the patient's mental capacity and physical heath should also be considered if targeting to less than 140 mm Hg
• Patients with diabetes should be treated to below 85 mm Hg diastolic BP
• Salt intake should be limited to approximately 5 to 6 g per day
• Body-mass index (BMI) should be reduced to 25 kg/m² and waist circumferences should be reduced to less than 102 cm in men and less than 88 cm in women
• Ambulatory BP monitoring (ABPM) should be incorporated into the assessment of risk
• Effective combination therapies include thiazide diuretics with ARBs, calcium-channel antagonists, or ACE inhibitors; or, calcium-channel antagonists with ARBs or ACE inhibitors
• Dual renin-angiotensin system blockade (ie, ARBs, ACE inhibitors, and direct renin inhibitors) is not recommended because of the risks of hyperkalemia, low BP, and kidney failure
• Although additional data is needed, renal denervation is a promising therapy in the treatment of resistant hypertension

ADA 2011 standard of medical care

The ADA 2011 standard of medical care states that in individuals with diabetes and mild hypertension, it may be reasonable to begin treatment with a trial of nonpharmacologic therapy (diet, exercise, and other lifestyle modifications.) Mild hypertension as defined by the ADA guideline (systolic BP 130-139 mm Hg or diastolic BP 80-89 mm Hg) may be classified as prehypertension by other organizations.^[60]

The ADA 2011 standards of medical care in diabetes also indicate that a majority of patients with diabetes mellitus have hypertension. In patients with type 1 diabetes, nephropathy is often the cause of hypertension, whereas in type 2 diabetes, hypertension is one of a group of related cardiometabolic factors.^{[60, 61]}Hypertension remains one of the most common causes of congestive heart failure (CHF). Antihypertensive therapy has been demonstrated to significantly reduce the risk of death from stroke and coronary artery disease.

Other studies have demonstrated that a reduction in BP may result in improved renal function. Therefore, earlier detection of hypertensive nephrosclerosis (using means to detect microalbuminuria) and aggressive therapeutic interventions (particularly with ACE inhibitor drugs) may prevent progression to end-stage renal disease.^[13]

JNC 7

Key messages of the JNC 7 were as follows^[4] :

• The goals of antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality, with the focus on controlling the systolic BP, as most patients will achieve diastolic BP control when the systolic BP is achieved
• Prehypertension (systolic 120-139 mm Hg, diastolic 80-89 mm Hg) requires health-promoting lifestyle modifications to prevent the progressive rise in BP and cardiovascular disease
• In uncomplicated hypertension, a thiazide diuretic, either alone or combined with drugs from other classes, should be used for the pharmacologic treatment of most cases
• In specific high-risk conditions, there are compelling indications for the use of other antihypertensive drug classes (eg, angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], beta blockers, calcium channel blockers)
• Two or more antihypertensive medications will be required to achieve goal BP (< 140/90 mm Hg or < 130/80 mm Hg) for patients with diabetes and chronic kidney disease
• For patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using 2 agents, one of which usually will be a thiazide diuretic, should be considered
• Regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan

Lifestyle modifications

Lifestyle modifications are essential for the prevention of high BP, and these are generally the initial steps in managing hypertension. As the cardiovascular disease risk factors are assessed in individuals with hypertension, pay attention to the lifestyles that favorably affect BP level and reduce overall cardiovascular disease risk. A relatively small reduction in BP may affect the incidence of cardiovascular disease on a population basis. A decrease in BP of 2 mm Hg reduces the risk of stroke by 15% and the risk of coronary artery disease by 6% in a given population. In addition, a prospective study showed a reduction of 5 mm Hg in the nocturnal mean BP and a possibly significant (17%) reduction in future adverse cardiovascular events if at least one antihypertensive medication is taken at bedtime.

Surgical intervention

Aortorenal bypass using a saphenous vein graft or a hypogastric artery is a revascularization technique for renovascular hypertension that has become much less common since the advent of renal artery angioplasty with stenting. Surgical resection is the treatment of choice for pheochromocytoma and for patients with a unilateral solitary aldosterone-producing adenoma, because hypertension is cured by tumor resection. In patients with fibromuscular renal disease, angioplasty has a 60-80% success rate for improvement or cure of hypertension. A promising therapy for resistant hypertension is renal denervation via a percutaneous approach. This catheter-based intervention is currently in the clinical trial phase.

Consultations

Consultations with a nutritionist and exercise specialist are often helpful in changing lifestyle and initiating weight loss. Consultations with an appropriate consultant are indicated for management of secondary hypertension attributable to a specific cause.