Category: Just So You Know

Iron Deficiency Anemia

Iron Deficiency Anemia

Patient education: Anemia caused by low iron

What is anemia? Anemia is the term doctors and nurses use when a person has too few red blood cells. Red blood cells are the cells in your blood that carry oxygen. If you have too few red blood cells, your body might not get all the oxygen it needs.

ANEMIA SIGNS AND SYMPTOMS Many people with iron deficiency anemia have no symptoms at all. Of those who do, the most common symptoms include:





●Difficulty exercising (due to shortness of breath, rapid heartbeat)

●Brittle nails

●Sore tongue

●Restless legs syndrome

●Pica (an abnormal craving to eat non-food items, such as clay or dirt, paper products, or cornstarch)

●Pagophagia (an abnormal craving to eat ice)

ANEMIA CAUSES Two common causes of iron deficiency anemia are blood loss (most common) and decreased absorption of iron from food.

Blood loss — The source of blood loss may be obvious, such as in women who have heavy menstrual bleeding or multiple pregnancies, or a person with a known bleeding ulcer. In other cases, the source of the blood loss is not visible, as in someone who has chronic bleeding in their gastrointestinal (GI) tract (stomach, small intestine, colon). This may appear as diarrhea with black, tarry stools, or, if the blood loss is very slow, the stool may appear normal. Donating blood can also cause iron deficiency, especially if it is done on a regular basis.

Decreased iron absorption — Normally, the body absorbs iron from food through the GI tract. If the GI tract is not functioning correctly, as is the case in people with certain conditions such as celiac disease, autoimmune gastritis, other forms of stomach inflammation, gastric bypass surgery (for weight loss), or other forms of weight loss surgery, an inadequate amount of iron may be absorbed, leading to iron deficiency anemia.

Other causes — A common cause of iron deficiency anemia in developing countries is a lack of foods that contain iron. However, this is rarely seen in adults in developed countries such as the United States because many foods contain iron, and others have added iron (breakfast cereal, bread, pasta). Iron is also available in some plant-based foods.

Pregnant and postpartum women may develop iron deficiency anemia because of the increased iron requirements of the growing fetus and placenta and blood loss at the time of delivery.

Is there a test for anemia? Yes, your doctor or nurse can test your blood for anemia. The things they most often check are the “hemoglobin level” and “hematocrit.” These show up on a test called the “complete blood count” or “CBC.”

How is iron deficiency anemia treated? The first step in treatment is to find out whether your anemia is caused by blood loss. If so, your doctor or nurse will want to find out why you are bleeding.

Blood loss can be related to stomach ulcers, bowel problems, or other issues. In women, blood loss can be related to heavy periods.

Whatever the cause of your anemia, your doctor or nurse can treat it by giving you iron. If the anemia is severe, you might need a blood transfusion. You might also need treatment for the cause of the bleeding.

People with iron deficiency anemia need to get iron. Eating foods with iron will not do enough to cure the anemia. You can get extra iron in pills or through a thin tube that goes into a vein, called an “IV.” Most people get it in pills. Your doctor or nurse will tell you how much to take, and for how long.

Iron pills can cause side effects such as upset stomach and constipation (too few bowel movements). If you have side effects, ask your doctor or nurse what to do. They can suggest ways to reduce these side effects or switch you to IV iron.

Adopted from UpToDate

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Telemedicine during COVID-19 Pandemic

Telemedicine during COVID-19 Pandemic

Telehealth and its role in coronavirus Pandemic:
Telehealth is the distribution of health-related services and information via electronic information and telecommunication technologies. It allows long-distance patient and clinician contact, care, advice, reminders, education, intervention, monitoring, and remote admissions.
New York State describes telehealth, for purposes of commercial products, as the use of electronic information and communication technologies by a health care provider to deliver health care services to an insured individual while such individual is located at a different site than where the health care provider is located.
While “telemedicine” has been more commonly used in the past, “telehealth” is a more universal term for the current broad array of applications in the field. Its use crosses most health service disciplines, including dentistry, counseling, physical therapy, and home health, and many other domains. Further, telehealth practice has expanded beyond traditional diagnostic and monitoring activities to include consumer and professional education. A connection exists between health information technology (HIT), health information exchange (HIE), and telehealth.
As our country responds to the unprecedented coronavirus pandemic, CMS is working rapidly to change the way we practice medicine to keep people safe. One critical innovation is the use of telehealth, which allows patients to use smartphones, laptops, and other widely available technologies to connect with your healthcare team.
For the duration of the pandemic, Medicare beneficiaries may now stay at home and use a commonly available interactive form of technology like FaceTime or Skype to have a telehealth office visit.
Some hospitals and practices have online portals available as well, but patients can also simply use their telephone. These developments are a game-changer for new and established patients, as well as their trusted clinicians
Medicare has added more than 80 new services that can be provided via telehealth, such as physical therapy, speech or hearing therapy, radiation treatment management, group psychotherapy, inpatient neonatal and pediatric critical care, and end-stage renal disease services.
During this pandemic, the option for telehealth has now been extended to home health, nursing home visits, and hospice as well. You can even make a “visit” to the emergency room through your phone. Crucially, Medicare copayments can be waived during this national crisis for all these telehealth services.
Telehealth helps doctors and other clinicians as well. It enables healthcare workers to safely work during this pandemic by greatly reducing their risk of exposure to COVID-19. And if they are quarantined, it opens the option of working from home. Telehealth allows them to continue to practice medicine, albeit in a different way, and remain available to their patients.
Moreover, this now-virtual workforce can be deployed to assess and treat patients at a distance, extending a lifeline to millions and providing convenient, continuous management of common chronic conditions like diabetes, hypertension, and more. These clinicians and therapists are helping their patients monitor illness and stay healthy during the COVID-19 pandemic.
Same is true for most of the commercial insurances including BCBS.
Providers will be paid Medicare level fees for telemedicine services even for Medicaid or uninsured patients. Commercial Insurances have already been paying for these services.

Rochester RHIO is committed to provide its services to 14 counties and 1.5 million clients its serves. Providers are able to log on to Explore query portal from their home while providing Telehealth services in these trying times. Federal and state have relaxed HIPPA guidelines for tele health services during COVID-19 pandemic. Rochester RHIO and other HIE in the NY state now are able to accept verbal consent documented in the encounter note as patient consent if provider is not sure that patient consent preexists. This has simplified the patient-provider connection from their respective homes for diagnosis and treatment at the same time maintaining safe distancing. Telehealth is here to stay as patients and providers gain valuable experience. Technology will keep improving and fees paid for the services will be further enhanced. CMS came through for their Medicare and Medicaid patients to allow access to telehealth and providers getting paid for it. Speed of decision and implementation of this program during this Pandemic was astounding. Rochester RHIO patient query portal EXPLORE is available 24/7 for patients, providers, hospitals, health systems, community based organizations, EMS, Nursing homes and from where ever patients and providers are accessing PHI.

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Coronavirus: Handwashing Education Flyer by World Health Organization

Coronavirus: Handwashing Education Flyer by World Health Organization

Education * Inform * Protect * Prevent

Many Thanks to Mr.Vinod Luthra for contributing this posting to GUTCHEK

Here are suggestions on how to protect yourselves and the well-being of our residents. The Centers for Disease Control and Prevention (CDC) recommends disinfecting all surfaces, washing hands for 20 seconds or using hand sanitizer, avoid handshakes, and staying home if you are not feeling well and notify a doctor immediately.

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Patient education: Coronavirus disease 2019 (COVID-19)

What is COVID-19?:  Coronavirus disease 2019, or “COVID-19,” is an infection caused by a specific virus called SARS-CoV2. It first appeared in late 2019 in the city of Wuhan, China. People with COVID-19 can have fever, cough, and trouble breathing. Problems with breathing happen when the infection affects the lungs and causes pneumonia
Experts are studying this virus and will continue to learn more about it over time.
How is COVID-19 spread?: Experts think COVID-19 first spread to people from animals in China that had the virus. But it can also be spread from person to person, like the flu.
Most cases of COVID-19 are in China. But there have been cases in other countries, too, including the United States. Most of these happened when people got the infection and then traveled to another country. In some cases, the virus then spreads to other people.
What are the symptoms of COVID-19?:  Symptoms usually start a few days after a person is infected with the virus. But in some people it can take even longer for symptoms to appear.
Symptoms can include:
●Trouble breathing
●Feeling tired
●Muscle aches
Some people have no symptoms, or only have mild symptoms. But in other people, COVID-19 can lead to serious problems like pneumonia, not getting enough oxygen, or even death. This is more common in people who have other health problems.
Should I see a doctor or nurse?:  If you have a fever with cough or trouble breathing and might have been exposed to COVID-19, call your doctor or nurse. You might have been exposed if you lived in or visited China in the 14 days before you got sick, or if you have been around a person who has the virus.
If your symptoms are not severe, it is best to call your doctor, nurse, or clinic before you go in. They can tell you what to do and where to go. If you do need to go to the clinic or hospital, you will need to put on a face mask. The staff might also have you wait some place away from other people.
If you are severely ill and need to go to the clinic or hospital right away, you should still call ahead. This way the staff can care for you while taking steps to protect others.
Your doctor or nurse will do an exam and ask about your symptoms. They will also ask questions about where you live, and whether you have had contact with people who might be sick or with animals.
Will I need tests? Yes. If your doctor or nurse suspects you have COVID-19, they will do tests on samples of fluid taken from inside your nose and mouth. They might also test fluid from your lungs, as well as your urine and stool (bowel movements). These tests can all show if you have COVID-19 or another infection.
Your doctor might also order a chest X-ray to check your lungs.
How is COVID-19 treated?:  Many people with COVID-19 have only mild illness and can rest at home until they get better. If you have more severe illness, you might need to stay in the hospital, possibly in the intensive care unit (also called the “ICU”). There is no specific treatment for the infection, but the doctors and nurses in the hospital can monitor and support your breathing and other body functions, and make you as comfortable as possible.
You might need extra oxygen to help you breathe easily. If you are having a very hard time breathing, you might need to be put on a ventilator. This is a machine to help you breathe.
Can COVID-19 be prevented?: There are things you can do to reduce your chances of getting COVID-19.
Some experts recommend avoiding travel to China or other countries where there are a lot of cases of COVID-19. If you do live or travel in one of these areas, try to stay away from people who have any symptoms of the infection. You can also protect yourself by washing your hands with soap and water often. Below are instructions on how to hand washing to prevent spreading illness
1. Wet your hands and put soap on them
2. Rub your hands together for at least 20 seconds. Make sure to clean your wrists, fingernails, and in between your fingers.
3. Rinse your hands
4. Dry your hands with a paper towel that you can throw away
If you are not near a sink, you can use a hand gel to clean your hands. The gels with alcohol in them work the best. But it is better to wash with soap and water if you can wash your hands to prevent spreading illness
You can also lower your risk of infection by avoiding animals and markets that sell animal products. Do not eat raw meat, and do not eat food that might have been in contact with animals without washing, peeling, or boiling it first.
If someone in your home has COVID-19, there are things you can to do protect yourself:
● Keep the sick person away from others – The sick person should stay in a separate room and use a separate bathroom if possible.
● Use face masks – The sick person should wear a face mask when they are in the same room as other people. If you are caring for the sick person, you can also protect yourself by wearing a face mask when you are in the room. This is especially important if the sick person cannot wear a mask.
● Be extra careful around body fluids – If you will be in contact with the sick person’s blood, mucus, or other body fluids, wear a disposable face mask, gown, and gloves. If any body fluids touch your skin, wash your hands with soap right away.
● Clean often – It’s especially important to clean things that are touched a lot. This includes counters, bedside tables, doorknobs, computers, phones, and bathroom surfaces.
● Wash hands – Wash your hands with soap and water often.
As we learn more about this virus, expert recommendations will continue to change. Check with your doctor or public health official to get the most updated information about how to protect yourself.
For more information login: 2.29.20
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Corona Virus (COVID-19) Comparison with Flu

Corona Virus (COVID-19) Comparison with Flu

Let’s Get Things in Perspective

Influenza and Novel Corona Virus Comparison

There is not a day that goes by that does not have something on the news about the COVID-19 (Coronavirus).  It is scary for some who have family and friends who may have connections with folks on cruise ships, living in China, travel, etc. The number of cases seems astronomical. What is frustrating is that it is a new virus, and we do not know much about it. Let us not forget that the flu is also spreading rapidly.

What we do know for now:

Flu COVID-19 Comments
Mode of Transmission Droplet

(Gown and Mask)

Regular Room


Gown, N-95/PAPR, goggles/Face shield

Negative Pressure if available or private room with door shut and surgical mask on client

Human to human for both

Both are Viral

Incubation period (time to grow and spread 24 hours before symptoms until 24-48 hours temperature free without benefit of Tylenol or aspirin 14 days from exposure. Can spread before symptoms even occur This is why some people returning from China have been placed in Quarantine for 14 days
Symptoms Fever, cough, sore throat, runny or stuffy nose, muscle or body aches, headache, tiredness (diarrhea and vomiting in children) Fever, cough and shortness of breath along with: travel to China, contact with a confirmed COVID-19 person, or having cared for a COVID-19 person with in the last 14 days Symptoms are both similar
Diagnostic Test Nasopharyngeal swab Nasopharyngeal Swab

Oropharyngeal Swab


Blood (Gold top serum separated tube)

Flu testing done in Bath

COVID-19 goes to CDC as directed by the Public Health Department

Treatment Tamiflu or Xofluza

Plus, symptom management

Symptom management
Vaccine  Yes No

If there is a suspected case of the COVID-19 Virus, the local Department of Health  where the patient lives will be notified.  No one who is suspected of COVID-19 will be discharged without a discharge plan from the Health Department.

One must practice good Public Health:

  • If sick… stay away from others, stay home (if you have a cough, sneezing, etc., from a cold, and  you come to work, please wear a mask!!)
  • Cover your mouth when you cough.
  • Keep your hands and fingers away from your eyes, mouth and nose.
  • Wipe down work areas, as well as areas at home (cell phones, tables, door knobs).
  • Eat healthy.
  • Get sleep.
  • Wash your hands.
  • Get a flu shot if you have not already done so. (If you did not get a flu shot, remember masks are available for you to wear.)

Remember, you can help prevent the flu or lessen the effects of the flu with a flu shot. There is no shot for Coronavirus.

So, to keep things in perspective

  Influenza COVID-19 Comments
Number of cases  106,000 + cases in NYS

15, 000,000 USA cases this year

0 cases NYS

19 patients checked outside NYC

6 in NYC

ALL negative with none pending currently.

15 Cases in the US

75,282 (Global for COVID-19)

140,000 people have been hospitalized for flu in the US this year

Number of Deaths 3 Pediatric (in NYS)

(state doesn’t indicate the number of deaths for adults…. but it is there)

12,000 Flu deaths USA this year


2,012 COVID-19 global

61,000 People died from the flu in 2017-18

Adapted from:  VA Newsletter 02/20/20

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Happy New Year, 2020

Happy New Year, 2020

Hi Friends,

Dawn of the New Year and new decade is here: Year 2020! Wow, did we imagine 20 years ago when Y2K was a big deal that 20 years would pass by so fast? With so much innovation, new ideas, and so many new medical advances!

I am excited to bring new insights and articles this year, and what I learn I want to pass to you. What I miss is feedback, positive and negative; it does not matter to me. I would like to improve the quality of topics and content of this blog in 2020.

Many times I wonder is it worth continuing the blog if there is no audience?
The medical world is changing so fast that it is hard to keep up with all of the changes and, at the same time, do a fact check. I like to alert my readers only to the topics and contents that are well established and accepted by majority of the medical community.

I am also delighted to report that I have been successful in patient advocacy and guiding folks as to where they can go for care at least in my geographic area of approach. This year, I will like to reach out to more folks and help.

Talk to you soon!

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Helicobacter Pylori (H. Pylori) Infection and Treatment

Helicobacter Pylori (H. Pylori) Infection and Treatment


Helicobacter pylori, also known as H. pylori, is a bacterium that is commonly found in the stomach. It is present in approximately one-half of the world’s population.

The vast majority of people infected with H. pylori has no symptoms and will never develop problems. However, H. pylori is capable of causing a number of digestive problems, including ulcers and, much less commonly, stomach cancer. It is not clear why some people with H. pylori get these conditions and others do not.


H. pylori is probably spread by consuming food or water contaminated with fecal matter. H. pylori causes changes to the stomach and duodenum (the first part of the small intestine). The bacteria infect the protective tissue that lines the stomach. This leads to the release of certain enzymes and toxins and activation of the immune system. Together, these factors may directly or indirectly injure the cells of the stomach or duodenum. This causes chronic inflammation in the walls of the stomach (gastritis) or duodenum (duodenitis).

As a result of these changes, the stomach and duodenum are more vulnerable to damage from digestive juices, such as stomach acid.

In the United States and other developed countries, infection with H. pylori is unusual during childhood but becomes more common during adulthood. However, in developing countries, most children are infected with H. pylori before age 10.


Most individuals with chronic gastritis or duodenitis have no symptoms. However, some people develop more serious problems, including stomach or duodenal ulcers.

Ulcers can cause a variety of symptoms or no symptoms at all, with the most common ulcer symptoms including:

  • Pain or discomfort (usually in the upper abdomen)
  • Bloating
  • Feeling full after after eating a small amount of food
  • Lack of appetite
  • Nausea or vomiting
  • Dark or tar-colored stools
  • Ulcers that bleed can cause a low blood count and fatigue

Less commonly, chronic gastritis causes abnormal changes in the stomach lining, which can lead to certain forms of cancer. It is uncommon to develop cancer as a result of H. pylori infection. Nevertheless, because so many people in the world are infected with H. pylori, it is considered to be an important cause of stomach cancer. People who live in countries in which H. pylori infection occurs at an early age are at greatest risk of stomach cancer.


There are several ways to diagnose H. pylori. The most commonly used tests include the following:

Breath tests — Breath tests (known as urea breath tests) require that you drink a specialized solution containing a substance that is broken down by the H. pylori bacterium. The breakdown products can be detected in your breath.

Stool tests — Tests are available that detect H. pylori proteins in stool.

Blood tests — Blood tests can detect specific antibodies (proteins) that the body’s immune system develops in response to the H. pylori bacterium. However, concerns over its accuracy have limited its use.


If you have symptoms:

Diagnostic testing for H. pylori infection is recommended if you have active gastric or duodenal ulcers or if you have a past history of ulcers.

Although H. pylori infection is the most common cause of ulcers, not all patients with ulcers have H. pylori. Certain medications (eg, aspirin, ibuprofen [Motrin, Advil], naproxen [Aleve]) can also cause peptic ulcers.

If you do not have symptoms:

H. pylori testing is usually not recommended if you have no symptoms and no past history of peptic ulcer disease. However, it may be considered for selected people, such as those with a family history or concern about stomach cancer, particularly individuals of Chinese, Korean, Japanese, or Central American descent; these groups have a higher incidence of stomach cancer.


People with a history of peptic ulcer disease, active gastric ulcer, or active duodenal ulcer associated with H. pylori infection should be treated. Successful treatment of H. pylori can help the ulcer to heal, prevent ulcers from coming back, and reduce the risk of ulcer complications (like bleeding). Guidelines in the United States and other countries recommend that patients who require long-term anti-inflammatory medications such as aspirin, ibuprofen, naproxen, and similar drugs treatment for arthritis and other medical conditions should be tested for H. pylori and if infected undergo treatment to eradicate the H. pylori infection.


No single drug cures H. pylori infection. Most treatment regimens involve taking several medications for 14 days.

  • Most of the treatment regimens include a medication called a proton pump inhibitor. This medication decreases the stomach’s production of acid, which allows the tissues damaged by the infection to heal. Examples of proton pump inhibitors include lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), rabeprazole (AcipHex), dexlansoprazole (Dexilant), and esomeprazole (Nexium).
  • Two antibiotics are also generally recommended; this reduces the risk of treatment failure and antibiotic resistance.
  • There are increasing numbers of patients with H. pylori infection that is resistant to antibiotics, so it is important to take all the medications prescribed and to have a test that confirms that the infection has been cleared.

For H. pylori treatment to be effective, it is important to take the entire course of all medications.

Side effects:

Up to 50 percent of patients have side effects while taking H. pylori treatment. Side effects are usually mild, and fewer than 10 percent of patients stop treatment because of side effects. For those who do experience side effects, it may be possible to make adjustments in the dose or timing of medication. Some of the most common side effects are described below.

  • Some of the treatment regimens use a medication called metronidazole (Flagyl) or clarithromycin (Biaxin). These medications can cause a metallic taste in the mouth.
  • Alcoholic beverages (eg, beer, wine) should be avoided while taking metronidazole; the combination can cause skin flushing, headache, nausea, vomiting, sweating, and a rapid heart rate.
  • Bismuth, which is contained in some of the regimens, causes the stool to become black and may cause constipation.
  • Many of the regimens cause diarrhea and stomach cramps.

Treatment failure:

Up to 20 percent of patients with H. pylori infection are not cured after completing their first course of treatment. A second treatment regimen is usually recommended in this case. Retreatment usually requires that the patient take 14 days of a proton pump inhibitor and two antibiotics. At least one of the antibiotics is different from those used in the first treatment course.


After completing H. pylori treatment, repeat testing is usually performed to ensure that the infection has resolved. This is typically done with a breath or stool test. Blood tests are not recommended for follow up testing; the antibody detected by the blood test often remains in the blood for four or more months after treatment, even after the infection is eliminated.


  • Helicobacter pylori, also known as H. pylori, is a bacterium that is commonly found in the stomach. Most people infected with H. pylori have no problems. However, some people develop problems, such as stomach ulcers.
  • Ulcers may cause no symptoms, or may cause pain or discomfort (usually in the upper abdomen), bloating, feeling full after eating a small amount of food, lack of appetite, nausea, vomiting, and dark or tar-colored stools. Ulcers that bleed can cause a low blood count.
  • H. pylori can be diagnosed with a test of the blood, breath, or stool.
  • H. pylori testing is recommended for anyone with a peptic (stomach or duodenal) ulcer.
  • Anyone diagnosed with H. pylori should be treated. H. pylori treatment helps to heal the ulcer, lowers the risk that the ulcer will return, and lowers the risk of bleeding from the ulcer.
  • H. pylori treatment usually includes several medicines. At least two of the medicines are antibiotics that help to kill the bacteria. The other medication causes the stomach to make less acid; lower acid levels help the ulcer to heal.
  • Most people are cured after finishing two weeks of medicine. Some people need to take another two weeks of medicine. It is important to finish all of the medicine to ensure that the bacteria are killed.
  • Guidelines recommend that all patients treated for H. pylori undergo a breath or stool test two weeks after finishing the medication. This is done to be sure that the bacteria were killed. It is recommended that the test is performed 30 days after the treatment is completed and off proton pump medication for 1 to 2 weeks before eradication testing.

Compiled from Up To date

Author: Sheila E Crowe, MD, FRCPC, FACP, FACG, AGAF

Professor of Medicine, University of California, San Diego

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Food Allergy Symptoms and Diagnosis

Food Allergy Symptoms and Diagnosis

Food Allergy Overview

Reactions to food are common and can be divided into two categories, those caused by food allergy and all other reactions. It is important to know the difference between food allergies and other illnesses or symptoms caused by foods because the management of each is different.

  • Food allergies develop when the body’s immune system has an abnormal reaction to one or more proteins in a food. Food allergies can lead to serious or even life-threatening allergic reactions.
  • Other food reactions are not caused by the immune system. These reactions cause unpleasant symptoms and are far more common than food allergies. Examples include lactose intolerance, heartburn (gastroesophageal reflux), bacterial food poisoning, and sensitivity to caffeine, just to name a few.

Classic Food Allergies

In people with “classic” food allergies, allergic antibodies, called immunoglobulin E (IgE), develop in response to proteins in certain foods. When the person is exposed to that protein at a later time (eg, by eating peanuts), binding of the food protein to IgE triggers a release of chemicals, which cause the symptoms of an allergic reaction. This typically occurs quickly, within minutes to two hours after eating.

Sudden-Onset Symptoms

The symptoms of a food allergy can vary from mild to severe or even life-threatening. It is not always possible to predict how severe symptoms will be based upon the symptoms experienced during a previous reaction. For example, a person could have mild hives after eating peanuts on one occasion and then have an anaphylactic reaction after eating peanuts another time. However, reactions are not necessarily worse after each exposure.

The most common sudden-onset symptoms of food allergy include:

  • Skin – Itching, flushing, hives (urticaria, like mosquito bites), or swelling (angioedema)
  • Eyes – Itching, tearing, redness, or swelling of the skin around the eyes
  • Nose and mouth – Sneezing, runny nose, nasal congestion, swelling of the tongue, or a metallic taste
  • Lungs and throat – Difficulty getting air in or out, repeated coughing, chest tightness, wheezing or other sounds of labored breathing, increased mucus production, throat swelling or itching, hoarseness, change in voice, or a sensation of choking
  • Heart and circulation – Dizziness, weakness, fainting, rapid, slow, or irregular heart rate, or low blood pressure
  • Digestive system – Nausea, vomiting, abdominal cramps, or diarrhea
  • Nervous system – Anxiety, confusion, or a sense of impending doom

Associated Conditions

Anaphylaxis — Generalized anaphylaxis is the most serious type of allergic reaction and can cause life-threatening signs and symptoms, including difficulty breathing, swelling of the upper throat and/or tongue, a very rapid or irregular heartbeat, low blood pressure, or cardiac arrest (the heart stops beating).

Generalized anaphylaxis generally begins within 5 to 60 minutes of exposure to a trigger, although, rarely, symptoms begin several hours after eating. A person who develops symptoms of anaphylaxis must be treated immediately with an injection of epinephrine. Treatment of anaphylaxis is discussed separately. Many different foods can potentially trigger anaphylaxis. In adults, peanuts, tree nuts (e.g., walnuts), fish, and shellfish cause most anaphylactic reactions. In children, peanuts and tree nuts are the most common causes of anaphylactic reactions.

Allergic rhinitis and conjunctivitis — Food allergies can trigger allergic symptoms in the nose, eyes, or throat. However, these symptoms usually occur along with whole-body symptoms, such as hives, difficulty breathing, diarrhea, etc. The most common nose, eye, and throat symptoms including a runny nose, congestion, sneezing, nasal itching, itchy or watery red eyes, or voices changes.

Oral allergy syndrome — Oral allergy syndrome, or pollen-food allergy syndrome, is seen in up to 50 percent of people with allergic rhinitis caused by pollen. In this condition, people who are allergic to pollen have an allergic reaction after eating certain raw (uncooked) fruits or vegetables. The reaction is immediate and can cause itching, irritation, and mild swelling of the lips, tongue, roof of the mouth, and throat. A list of pollens and foods that cross react is available in the figures.

Risk of clinical reactivity among related fruits and vegetables

Cross-reactivity patterns in pollen-food allergy syndrome

Symptoms of oral allergy syndrome may be more noticeable during the associated pollen season. Symptoms usually resolve within minutes after the person stops eating the food. Most people have only localized symptoms (eg, in the mouth).

Less than 10 percent of people have systemic symptoms to fruits and vegetables (eg, vomiting or diarrhea), and 1 to 2 percent of people develop generalized anaphylaxis. People with a history of systemic symptoms should carry epinephrine auto injectors.

The reaction does not usually occur if the fruits or vegetables are cooked. Tree nuts and peanuts are an exception to this, meaning that anyone with a history of an oral allergy to nuts should avoid them in all forms (raw, roasted, and cooked).

Food-dependent exercise-induced anaphylaxis — There are some people who develop an anaphylactic reaction after eating a certain food and then exercising up to four hours later. A reaction can occasionally occur after exercising first and then eating. The particular food does not cause anaphylaxis if the person does not exercise. This is called food-dependent exercise-induced anaphylaxis.

The most common foods associated with this condition include wheat, celery, and seafood, although some people react after eating any food and then exercising. Not eating for several hours before exercise can usually prevent this type of reaction.


There are several conditions that may be food related, such as eosinophilic gastrointestinal disorders (eosinophilic esophagitis) atopic dermatitis (eczema).


Food allergies can occur without involving immunoglobulin E (IgE). The symptoms of this type of food allergy are usually slower to develop and longer lasting than those of classic food allergies.

The three main types of non-IgE food allergies are:

  • Food protein-induced enterocolitis
  • Food protein-induced proctocolitis
  • Celiac disease and dermatitis herpetiformis

Most of these conditions cause symptoms of the digestive system, such as vomiting, diarrhea, abdominal pain, and/or blood in the stool. Food protein-induced enterocolitis and proctocolitis are more commonly seen in infants.


Anyone who has signs or symptoms of a food allergy should see his or her health care provider. Between 20 and 30 percent of people report food allergy in themselves or their children. However, only 6 to 8 percent of children under the age of five and 3 to 4 percent of adults have a true food allergy.

Laboratory testing and/or skin testing is often used to confirm the food allergy and determine if avoidance of a particular food is necessary.

Medical history — During a medical history, the health care provider will ask questions about the person’s past allergic reactions:

  • What symptoms of food allergy did you have?
  • What particular food do you think provoked the reaction? Have you eaten this food before? Have you reacted before?
  • How much of this food did you eat?
  • What other foods did you eat at that time? Do you know all the ingredients of the food you ate? Include all foods: appetizer, main dish, sauces, dressings, breads, beverages, and side dishes.
  • How was the food prepared? As an example, could the food have been fried in oil used to prepare other foods?
  • Were any of following eaten: peanuts, tree nuts, shellfish, fish, milk, eggs, wheat, or soy?
  • How much time passed between eating the food and the first symptoms?
  • Did you exercise or exert yourself after eating?
  • Did you take any medications, herbs, vitamins, nonprescription medications, or drink any alcohol before or after eating?
  • How was the reaction treated? Did it resolve without treatment or did you take any medications? How long were the medications continued, and were there any later symptoms?

Depending upon the answers to these questions and the physical examination, the health care provider may decide to order laboratory testing. In other cases, the provider will refer the person to a specialist (allergist or gastroenterologist) for further evaluation.

Allergy testing:

Testing for food allergies often includes skin testing and/or blood tests. Depending upon the situation, tests may be done to determine if a person is allergic to pollens, insects, latex, and other allergens. However, testing is only recommended if the person is suspected to have an allergy. As an example, if a person had a reaction after eating peanuts, but has never reacted to wheat or eggs and eats them regularly, it is not necessary to test for allergy to wheat or eggs.

Skin testing:

Skin testing involves pricking/scratching the skin with a tiny probe that is coated with food extract or fresh food. The pricks are usually done on the forearm or upper back after the skin is cleaned with alcohol. The skin prick is not usually painful.

Adults and children of any age may have skin testing. The test may result in small hives (like a mosquito bite) at the site of the prick/scratch. Only a trained health care provider, usually an allergy specialist, should do skin testing. This specialist will evaluate the size of the test results to assist in making a diagnosis.

Blood tests:

Blood tests are available to assist doctors in making a diagnosis. Neither the skin test nor the blood test can be depended upon to make a diagnosis without a clinician considering the medical history and other supporting information. Blood tests are widely available and do not require an allergy specialist to perform the test. However, consultation with an allergy specialist may be recommended to interpret the results of the test.

Elimination diets:

An elimination diet is a specially designed diet that eliminates one or more foods or groups of food from a person’s diet for a period of time. The food is then added back to determine if signs or symptoms of a food allergy develop.

An elimination diet may be recommended as part of the process of determining if a person has food allergies. An allergist or dietitian must be involved in designing an elimination diet because avoiding entire groups of foods (eg, milk) could potentially lead to malnutrition, especially in infants and children. An elimination diet by itself does not often lead to the diagnosis of food allergy.

During an elimination diet, it is important to read food labels carefully. In the United States, the Food Allergen Labeling and Consumer Protection Act mandates that nutritional labels on food packages plainly identify eight specified food allergen sources (milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat, and soy), although other foods may still appear under multiple names.

In addition, patients must understand that “substitute” foods, which reduce or eliminate fat or other components of a food, still contain the allergenic proteins. As an example, some egg substitutes (which are lower in cholesterol) still contain egg white proteins.

Food diary:

A health care provider may request that a person keep a complete record of everything they eat over a period of time, including all foods, drinks, condiments, and candies.

Food challenges:

If it is not clear if a person has a food allergy, based upon their medical history and allergy testing, he or she may be offered a medically supervised gradual feeding or food challenge. A food challenge may also be recommended if there is reason to believe that the food allergy has resolved. In addition, some foods such and egg and milk become less allergenic when they are extensively heated (eg, baked in bread or muffins), and a challenge may be performed to find out if the person is able to eat the food in this form. A food challenge is done by giving the person a tiny amount of the potentially allergenic food to eat.

After the person is given the first sample of food, he/she is observed for 10 to 30 minutes. If there is no reaction, a slightly larger amount of the food is given. This is continued for approximately 90 minutes or more. If the person develops signs or symptoms of an allergic reaction, the food challenge is immediately stopped.

Food challenges should only be performed in a setting where the personnel and equipment needed to treat anaphylaxis are available; this can be an office or hospital setting.

  • Preparing for the food challenge – The doctor or nurse will provide specific instructions before the food challenge. It is important to prepare by not eating or drinking for two hours before the test, and certain medications may need to be stopped days or weeks before. The person should bring their epinephrine auto injector to the food challenge in case they develop a delayed allergic reaction on the way home.
  • If there is no reaction during the food challenge – If the person did the food challenge to find out if he or she has an allergy and does not have any signs of an allergic reaction during the food challenge, he/she probably does not have an allergy to the tested food. However, the person may have allergies to other foods, so it is important to understand when/if foods should continue to be avoided.
  • If the person already has a known allergy to a food (such as egg or milk) but passes a challenge for that food in extensively heated form, he or she still needs to be careful to avoid the food in raw or less cooked form. For example, a person with a milk allergy might be able to eat bread or processed foods that contain milk but still need to avoid drinking milk and eating dairy products like cheese or yogurt. A doctor or nurse will discuss the results of the food challenge and give recommendations on what to do moving forward.


It is sometimes difficult to know if a reaction is caused by a true food allergy or a food intolerance. Anyone who has one or more of the following symptoms after eating should seek medical care:

  • Nausea or vomiting
  • Cramping, abdominal pain, or diarrhea, especially if there is blood or mucus in the stool
  • Itching or raised red welts on the skin
  • Flushed (reddened, warm) skin
  • Swelling of the lips, mouth, face, or throat
  • Wheezing, coughing, or difficulty breathing
  • Lightheadedness or passing out.

Compiled from Up To Date:
Author: Wesley Burks, MD
University of North Carolina School of Medicine

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Patient Education: Obesity and Bariatric Surgery

Patient Education: Obesity and Bariatric Surgery

Weight loss surgery, sometimes called bariatric surgery, is a surgery to help you lose weight. It works by making you take in fewer calories and nutrients. Doctors use a measure called “body mass index” or BMI, to decide who can have this weight loss surgery. Your BMI will tell you whether your weight is normal for your height. (See BMI Chart in my previous postings.)

Weight loss surgery is appropriate only if you have not been able to lose weight through other means and if you:

  • have a BMI above 40 and have not responded to diet, exercise, or weight loss medicines; or
  • have a BMI above 35 and also have a medical problem related to obesity, such as diabetes, heart disease, or high blood pressure; or
  • have a BMI above 30, but only if you have certain medical conditions.

Types of Surgery

Gastric Bypass: Gastric bypass is short for “Roux-en-Y Gastric Bypass,” and sometimes called “RYGB.” For this surgery, the doctor closes off part of the stomach, leaving only a small pouch for food. Then, he or she connects the stomach pouch to the middle part of the small intestine. This allows food to “bypass” or reroute around a part of the stomach and small intestine. There are other surgeries that are simlar to gastric bypass in how they cause weight loss.

Gastric Sleeve: Gastric sleeve, also known as “sleeve gastrectomy,” is a surgery that turns the stomach into something that looks like a sleeve. In other words, the doctor removes a large portion of the stomach and leaves a narrow tube.

Gastric Balloon: For this, the doctor puts a special balloon into your stomach. He or she does this using a thin tube that goes into your mouth and down your throat. The balloon stays in your stomach for up to 6 months. While it is there, your stomach has less space for food, which limits the amount you can eat at one time.

Gastric bypass and gastric sleeve can be done as “open” surgery or as a laparoscopic surgery. For open surgery, the surgeon cuts open the belly and works on the organs directly. For laparoscopic surgery, the surgeon makes a small cut and inserts a narrow tool that has a tiny camera on the end into the belly. This tool is called a laparoscope. It allows the surgeon to see inside the belly without opening it up all the way. Then, the surgeon can do the surgery using other tools that fit through small openings in the belly and that can be controlled from the outside.

Gastric balloon is a procedure, it is not actually a surgery. It does not involve cutting the skin the way the other options do.

Each type of weight loss surgery is different and each has different benefits and downsides.

  • Gastric Bypass leads to the most weight loss and works the fastest, but it involves the most serious surgery with the highest risks. It can also cause problems in how your body absorbs nutrients. As a result, it can lead to “nutritional deficiencies,” meaning your body is missing important nutrients. This can sometimes make you sick. If you have gastric bypass, your doctor will monitor your nutrient levels afterward.
  • Sleeve Gastrectomy is safer than gastric bypass because it does not involve rerouting or cutting and reattaching the intestines, and because it is less likely to cause problems with how you absorb nutrients. It might also be safer because it does not involve any plastic materials that stay in your body.
  • Gastric balloon is becoming a more popular option for weight loss. That’s because it is safe, easy-to-do, and does not involve any cutting. But, it also does not lead to as much weight loss as the other surgical options. After the balloon is removed, some (but not all) people are able to keep the weight off.

The decision about which type of surgery to have is important. Discuss your choices with your doctor. If you have different options, ask the following questions.

  • About how much weight can I expect to lose with each option?
  • How long will it take me to lose the weight?
  • What are the risks of each option for someone like me?
  • What changes will I need to make to my diet and lifestyle with each option?

Whatever you decide, make sure your surgeon is experienced with weight loss surgery. Also, check with the staff at your treatment center, or make sure it is a certified “Center of Excellence.” Those centers have a team of nurses and doctors who specialize in taking care of patients like you. If you are unsure about your decision, you can ask for an opinion from another doctor. Most hospitals that have experience with weight loss surgery offer patient education sessions where you can learn more about weight loss surgery and the options you have.

In addition to helping you lose weight, surgery can help improve or even get rid of certain health problems including:

  • diabetes
  • high blood pressure
  • high cholesterol
  • sleep apnea, a condition that causes you to stop breathing for short amounts of time while you sleep.

The risks of surgery are different depending on the following.

  • What type of weight loss surgery you have.
  • Whether your surgery is open or laparoscopic.
  • Your age and overall health.
  • How experienced your surgeon is.

In general, the risks could include:

  • Bleeding
  • Infection inside the belly or in the wounds from surgery
  • Leaks from the incisions on the stomach or intestine
  • A blockage or tear in the intestines
  • Problems with the heart or lungs
  • Gallstones
  • Nutritional problems
  • Severe diarrhea
  • Need for more surgery

As with any kind of surgery, it is possible for these procedures to lead to serious problems or even death. Death following weight loss surgery is very rare. But it’s still important to talk to your doctor about all the possible risks of each type of surgery.

You will need to eat healthy foods that “work with” your surgery. For example, you should choose foods high in protein and low in fat and calories. You should also avoid liquid foods that are high in calories, such as ice cream. If you eat the wrong things, you could hurt your chances of losing weight.

If you have weight loss surgery, you will need to avoid certain foods that could make you sick. Plus you will probably need to take special multivitamins with minerals. That’s because weight loss surgery, especially gastric bypass, can make it hard for your body to get all the nutrition it needs. You must keep taking vitamins for the rest of the life. Your body will always need them to stay healthy.

Adopted from Up-to-Date Education Basics.

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2018 Cholesterol Clinical Practice Guidelines: Synopsis of the 2018 American Heart Association/American College of Cardiology/Multi society Cholesterol Guideline

2018 Cholesterol Clinical Practice Guidelines: Synopsis of the 2018 American Heart Association/American College of Cardiology/Multi society Cholesterol Guideline

CLINICAL GUIDELINES |4 JUNE 2019 Annals Of Internal Medicine

According to the Centers for Disease Control and Prevention, heart disease is the leading cause of death in the United States, including for African American, Hispanic, and white persons (1) and for both women and men. The leading cause of death attributable to cardiovascular disease (CVD) in the United States is coronary heart disease (43.8%), followed by stroke (16.8%)—the 2 components of fatal atherosclerotic CVD (ASCVD) (2). The economic impact of ASCVD is large: It accounted for 14% of total health expenditures in 2013 to 2014, more than any major diagnostic group.

The American Heart Association and American College of Cardiology (AHA/ACC), with the support of 10 collaborating organizations, have recently released their 2018 cholesterol guideline (3). In addition, they have released a companion special report on the use of risk assessment tools to guide decision making in primary prevention 


The guideline endorses a heart-healthy lifestyle beginning in childhood to reduce lifetime risk for ASCVD. It contains several new features compared with the 2013 guideline. For secondary prevention, patients at very high risk may be candidates for adding nonstatin medications (ezetimibe or proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors) to statin therapy. In primary prevention, a clinician–patient risk discussion is still strongly recommended before a decision is made about statin treatment. The AHA/ACC risk calculator first triages patients into 4 risk categories. Those at intermediate risk deserve a focused clinician–patient discussion before initiation of statin therapy. Among intermediate-risk patients, identification of risk-enhancing factors and coronary artery calcium testing can assist in the decision to use a statin. Compared with the 2013 guideline, the new guideline gives more attention to percentage reduction in low-density lipoprotein cholesterol as a treatment goal and to long-term monitoring of therapeutic efficacy. To simplify monitoring, nonfasting lipid measurements are allowed.

Synopsis of Recommendations

1. Healthy lifestyle over the lifespan. A healthy lifestyle reduces ASCVD risk at all ages. In younger persons, healthy lifestyle can reduce development of risk factors, can prevent the need for subsequent statin use, and is foundational therapy for ASCVD risk reduction. In young adults aged 20 to 39 years, an assessment of lifetime risk facilitates the clinician–patient risk discussion and emphasizes intensive lifestyle efforts. In all age groups, lifestyle therapy is the primary intervention for metabolic syndrome.

2. Use of maximally tolerated doses of statins in secondary prevention of ASCVD. In patients with clinical ASCVD, the guideline recommends reduction of low-density lipoprotein cholesterol (LDL-C) levels with high-intensity or maximally tolerated statin therapy. The more LDL-C is reduced during statin therapy, the greater the subsequent risk reduction will be. High-intensity statins typically reduce LDL-C levels by an average of at least 50%, which is an attainable goal in most patients with ASCVD.

3. Use of nonstatin medications in addition to statin therapy for patients at very high risk for ASCVD. Very high risk is defined as a history of multiple major ASCVD events, or 1 major ASCVD event and multiple other high-risk conditions. In very-high-risk ASCVD, the guideline recommends an LDL-C threshold of 1.8 mmol/L (70 mg/dL) as reasonable for adding a nonstatin medication (ezetimibe or proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors) to maximally tolerated statin therapy. In patients who had very high risk, had a baseline LDL-C level of approximately 1.8 mmol/L (70 mg/dL), and were receiving statin therapy, addition of ezetimibe reduced risk for major events by 2 percentage points (6). Two RCTs recruited patients at very high risk who were receiving maximally tolerated doses of statins, had LDL-C levels greater than 1.8 mmol/L (70 mg/dL) (average, about 2.3 mmol/L [90 mg/dL]), and were treated with PCSK9 inhibitors for approximately 3 years (7, 8). Addition of PCSK9 inhibitors reduced risk for subsequent ASCVD events by about 15%. On the basis of these RCTs, the guideline states that addition of ezetimibe to maximally tolerated statin therapy is reasonable when LDL-C levels are 1.8 mmol/L (70 mg/dL) or higher. In patients at very high risk whose LDL-C levels remain above this threshold while they receive maximally tolerated statin and ezetimibe therapy, the guideline suggests that a PCSK9 inhibitor is a reasonable addition, although long-term safety (>3 years) is uncertain and cost-effectiveness was low at mid-2018 list prices. Some prescription programs have recently been initiated to reduce the cost of PCSK9 inhibitors. As cost decreases, cost-effectiveness will increase (9).

4. Severe primary hypercholesterolemia, often starting in childhood. In patients with primary, severe hypercholesterolemia (LDL-C level ≥4.9 mmol/L [≥190 mg/dL]), calculating 10-year ASCVD risk is not necessary. Maximally tolerated statin therapy is required to reduce LDL-C levels toward a lower risk range. If the LDL-C level remains at or above 2.6 mmol/L (100 mg/dL), adding ezetimibe is reasonable. If the patient still has an LDL-C level above this threshold while receiving a statin plus ezetimibe and has multiple factors that increase subsequent risk for ASCVD events, a PCSK9 inhibitor may be considered, although long-term safety (>3 years) is uncertain and economic value is low based on list prices from mid-2018.

5. Adults aged 40 to 75 years with diabetes mellitus and an LDL-C level of 1.8 mmol/L (70 mg/dL) or higher. In these patients, the guidelines recommend starting moderate-intensity statin therapy without the need to calculate 10-year ASCVD risk. In patients with diabetes and higher risk, especially those who have multiple risk factors or are aged 50 to 75 years, use of a high-intensity statin is reasonable to reduce the LDL-C level by at least 50%.

6. Clinician–patient risk discussion. In adults aged 40 to 75 years who are evaluated for primary ASCVD prevention, the guidelines continue to recommend a clinician–patient risk discussion before statin therapy is started. Risk discussion should include review of major risk factors (such as cigarette smoking and elevated levels of blood pressure, LDL-C, hemoglobin A1c level [if indicated], or calculated 10-year risk for ASCVD), risk-enhancing factors (see recommendation 8), the potential benefits of lifestyle and statin therapies, the potential for adverse effects and drug–drug interactions, consideration of costs of statin therapy, and patient preferences and values in shared decision making.

7. Adults aged 40 to 75 years without diabetes mellitus who have LDL-C levels of at least 1.8 mmol/L (70 mg/dL), and a 10-year ASCVD risk of 7.5% or higher. In this population, the guidelines recommend moderate-intensity statin therapy if a discussion of treatment options favors statins. Patients without ASCVD are categorized and stratified for risk by age, coexisting conditions, and risk factors (Figure). When those with diabetes or LDL-C levels above 4.9 mmol/L (190 mg/dL) are excluded, RCT evidence for the benefit of statin therapy in persons aged 40 to 75 years continues to accumulate (10). Patients in this age range are triaged into 4 categories of 10-year risk for ASCVD: low (<5%), borderline (5% to 7.4%), intermediate (7.5% to 19.9%), and high (≥20%). In the latter category, the guideline recommends high-intensity statin therapy because of its proven benefit. Evidence from RCTs supports the efficacy of statin therapy for patients whose 10-year risk is 5% or higher. Nonetheless, in those with borderline or intermediate risk, clinical judgment is required to initiate statin treatment on the basis of risk–benefit considerations and patient preferences.

8. Decision making in primary prevention in adults aged 40 to 75 years. The guideline endorses a 3-tiered decision process for treatment in adults aged 40 to 75 years with borderline (5% to 7.4%) or intermediate (7.5% to 19.9%) risk for ASCVD. The decision process begins with estimation of 10-year risk. As in prior guidelines, 10-year risk of 7.5% or higher does not result in automatic statin assignment. To personalize risk, the current guideline recommends evaluation of risk-enhancing factors—that is, stable factors that associate with ASCVD beyond the major risk factors incorporated into the risk calculator. These include family history of premature ASCVD; LDL-C levels of 4.1 mmol/L (160 mg/dL) or higher; metabolic syndrome; chronic kidney disease; history of preeclampsia or premature menopause (in women); chronic inflammatory disorders; high-risk ethnicity, such as South Asian ancestry; triglyceride levels persistently elevated above 2.0 mmol/L (175 mg/dL); and, if measured, elevations in apolipoprotein B (may be especially useful if hypertriglyceridemia >2.3 mmol/L [>200 mg/dL] persists), high-sensitivity C-reactive protein levels of 19.0476 nmol/L (2.0 mg/L) or higher, lipoprotein(a) levels with elevations above 125 nmol/L (50 mg/dL) (especially useful in those with a family history of premature ASCVD), or reduced ankle–brachial index. Presence of risk-enhancing factors in patients at intermediate risk favors statin therapy. In addition, if risk status remains uncertain, measurement of coronary artery calcium (CAC) can be considered.

9. CAC scoring to improve risk stratification. In adults who do not have diabetes, are aged 40 to 75 years, have LDL-C levels of 1.8 to 4.9 mmol/L (70 to 189 mg/dL), and have a 10-year risk of 7.5% to 19.9% as estimated by the pooled cohort equations (PCEs), but who are uncertain about statin benefit, CAC scoring may help resolve the uncertainty. If the CAC score is 0 Agatston units, statin therapy may be withheld or delayed, except in cigarette smokers and those with a strong family history of premature ASCVD or diabetes. A CAC score of 1 to 99 units favors statin therapy, especially in patients older than 55 years. For any patient, if the CAC score is at least 100 Agatston units or is at or above the 75th percentile, statin therapy is indicated unless otherwise deferred by the outcome of a clinician–patient risk discussion.

10. Follow-up for adherence and adequacy of response. The current guideline continues to recommend assessment of adherence to medications and lifestyle and percentage change in LDL-C level at 4 to 12 weeks after statin initiation or dosage adjustment; this assessment should be repeated every 3 to 12 months as needed. Clinicians may often underestimate adherence unless specific questions are asked (11).

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