· Examples on such treatments: arnica creams, apple cider vinegar compresses, epsom salt baths, bromelain, tea bags and aloe vera gel. 

 Menopause is a part of women aging process in where her ovaries produce low level of estrogen and progesterone and when she no longer can become pregnant and is the permanent cessation of menstruation

1. Taking calcium and vitamin D supplements can help to prevent osteoporosis 
2. Cutting down on saturated fat and replacing it with unsaturated fats
3. Reducing salt intake
4. Consuming fish, or taking omega 3 supplements
5. Eating high fiber and wholegrain foods; Maintaining a healthy bodyweight
6. Physical activity can help to manage some menopause symptoms

 Miscarriage definition:

- Lactating : 500 mcg 

• Nausea and vomiting of pregnancy is commonly referred to as morning sickness (although it can occur at any time of the day or night), it is one of the most common symptoms as it affects about 70% of pregnant women in varying degrees. 

•  Symptoms usually appear at 4–9 weeks of gestation, reaching a peak at 7–12 weeks, and subsiding by week 16. About 15-30% of pregnant women’s symptoms will persist beyond 20 weeks, or even up to the time of delivery. 

• The etiology of nausea and vomiting of pregnancy remains unknown, but numbers of possible causes have been investigated, including: slowed movement of the stomach contents, hormones, H.pylori, stress and fatigue.  

• Prehypertension – Systolic and/or diastolic BP ≥90 ^th percentile but <95 ^th percentile or if BP exceeds 120/80 mmHg

• Hypertension (HYPERTENSION) – HYPERTENSION is defined as either systolic and/or diastolic BP ≥95 ^th percentile measured upon three or more separate occasions.
• Stage 1 hypertension – Systolic and/or diastolic BP between the 95 ^th percentile and 5 mmHg above the 99 ^th percentile.

• Stage 2 hypertension – Systolic and/or diastolic BP ≥99 ^th percentile plus 5 mmHg.

• Primary: no identified cause of hypertension.
• Secondary: hypertension is due to a certain cause.

• Symptomatic patients (headache, seizures, changes in mental status, focal neurologic complaints, visual disturbances, and cardiovascular complaints indicative of heart failure, such as chest pain, palpitations, cough, or shortness of breath).
• Stage 2 HYPERTENSION defined above.
• Stage 1 hypertension that persists despite a trial of four to six months of non-pharmacologic therapy.
• Hypertensive target-organ damage, most often left ventricular hypertrophy (LVH).
• Stage 1 hypertension in patients with diabetes mellitus or dyslipidemia
• Prehypertension in presence of comorbid conditions, such as chronic kidney disease or diabetes mellitus.

• In children and adolescents with hypertension and no evidence of target-organ damage, comorbid risk factors, or cardiovascular disease; the targeted goal is less than the 95 ^th percentile based upon age, height, and gender.
• If there are comorbid risk factors (eg, obesity or dyslipidemia), cardiovascular diseases (eg, diabetes mellitus), or chronic kidney disease, the BP targeted goal is lowered to below the 90 ^th percentile for age, height, and gender.

Hypertension is the one of the most common cardiovascular conditions that must be treated aggressively to prevent any complication, including myocardial infarction, stroke, renal failure, and death.

According to the JNC 8 guidelines, hypertensive patients over 60 years old must be treated with a blood pressure goal of less than 150/ 90 mm HG, while younger hypertensive patients (less than 60 years) should be treated with a goal of less than 140/90 mm Hg including diabetic patients and patients with chronic kidney disease.

Initial treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). Except for black population, treatment should include a thiazide-type diuretic or CCB.

The JNC 8 did not recommend β-blockers for the initial treatment of hypertension because it resulted in a higher rate of cardiovascular death, myocardial infarction, or stroke compared to use of an ARB.

Also they don’t recommend using α-Blockers as first-line therapy because in one study initial treatment with an α-blocker resulted in worse cerebrovascular, heart failure, and combined cardiovascular outcomes than initial treatment with a diuretic.

According to studies Initial treatment with a thiazide-type diuretic was more effective than a CCB or ACEI for preventing heart failure, and an ACEI was more effective than a CCB in improving heart failure outcomes.

For patients with chronic kidney disease (regardless of race), treatment should include an ACEI or ARB as these agents improve kidney function.

Agents approved by JNC8 for hypertension treatment:

Our goal is to maintain blood pressure goals according to age; ensuring patient adherence to treatment and to lifestyle measure ( low sodium diet, weight control, avoid smoking and exercise) is important to achieve your goal. if goal can be achieved with one agent we can increase the dose to the maximum and then add another agent from another class (thiazide-type diuretic, CCB, ACEI, or ARB). If goal is still not reached with 2 drugs with maximum doses we can add a third agent. Do not use an ACEI and an ARB together in the same patient. If blood pressure goal is still not achieved after using 3 agents, antihypertensive drugs from other classes can be used (eg, β-blocker, aldosterone antagonist, or others)

The treatment of osteoporosis in men consists of lifestyle measures and drug or hormonal therapy.

Non pharmacological therapy

1.   Weight-bearing exercise.

2.   Calcium and vitamin D supplementation:

1000 -1200 mg of calcium daily and 600-800 units of vitamin D

Secondary osteoporosis:

 The cause of secondary osteoporosis should be identified and treated.

For example Testosterone therapy  can be used to increase bone mineral density in young men with hypogonadism

Pharmacological therapy:

We start with fracture risk assessment using FRAX score calculator which estimates the 10-year probability of hip fracture or major osteoporotic fractures combined (hip, spine, shoulder, or wrist) for an untreated patient using femoral neck BMD and other risk factors for fractures:

http://www.shef.ac.uk/FRAX/tool.aspx?country=1

When to start pharmacotherapy?

1.   Men ≥50 years with a history of hip or vertebral fracture or with osteoporosis (T-score ≤-2.5).

2.    Men with osteopenia (T-score between -1.0 and -2.5) and with a10-year probability of hip fracture reaches 3 percent or the 10-year probability of osteoporotic fractures combined is ≥20 percent.

3.   For those at moderate risk (10 to 20 percent), the decision to treat should be based upon the presence of additional risk factors.

Choice of therapy  

Bisphosphonates are considered the treatment of choice.

Patients can start with weekly alendronate and risedronate, when oral bisphosphonate is intolerable patients can use IV zoledronic acid.

When zoledronic acid is intolerable or for patients with renal impairment (bisphosphonates are not recommended when GFR<30 ml/min), denosumab is the drug of choice.

 Another option is Teriparatide, which can be used for men with severe osteoporosis (T score <-2.5) and at least one fragility fracture), or men who have failed previous therapy.

Denosumab prevents bone loss and reduces vertebral fracture risk in men with nonmetastatic prostate cancer receiving androgen deprivation therapy. Also, used in males with impaired renal function.

  In case of treatment failure and no availability of another option, strontium ranlate can be used which acts by inhibiting bone resorption and may increases bone mineral density.

In males whit growth hormone deficiency, Growth hormone growth factor can be used

Monitoring:

1.   Patient adherence to therapy

2.    BMD measurements, obtain a follow-up DXA of hip and spine after two years, and if BMD is stable or improved, less frequent monitoring is needed.

Osteoporosis is a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D.

Prevention:

Some life style changes can be done to prevent osteoporosis, including the following:

1.maintain an adequate calcium and vitamin D levels is the first step in preventing osteoporosis.

Post-menopausal females should have a calcium intake of 1200 mg/ day as a total level from both food and calcium supplements. Calcium supplements can be taken as 500-1000 mg daily with meals. Vitamin D supplements may be needed to maintain D3 blood level of 30-60 ng/ml.

2. Limit alcohol intake to less than 2 servings daily

3. Limit caffeine intake

4. Moderate exercise 30 minutes daily

5. Avoid smoking

Screening:

Who should screen for osteoporosis?

1.     Female 65 years and older.

2.     Younger postmenopausal women with fractures risk factors (Prior low-trauma fracture as an adult, Advanced age, Low bone mineral density Low body weight or low body mass index, Family history of osteoporosis, Use of corticosteroids Cigarette smoking Excessive alcohol consumption Secondary osteoporosis)

Diagnosis:

Osteoporosis is diagnosed using a central dual-energy x-ray absorptiometry (DXA) measurement.

In the absence of fracture, osteoporosis is defined as a T-score of -2.5 or below in the spine, femoral neck, or total hip.

Osteoporosis is defined as the presence of a fracture of the hip or spine.

Pharmacological treatment:

Once patient is diagnosed with osteoporosis (history of a hip or spine fracture, No fractures but with a T-score of -2.5 or lower, Patients with a T-score between -1.0 and -2.5 if FRAX major osteoporotic fracture probability is ≥20% or hip fracture probability is ≥3%)

Bisphosphonates:

 Bisphosphonates are first-line therapy for postmenopausal osteoporosis. We prefer oral bisphosphonates as initial therapy because of their efficacy,long term safety data and low cost.

In cases of intolerance to gastrointestinal side effects, we can use IV zaledronic acid, which has been demonstrated to reduce vertebral and hip fractures.

also, denosumab can be used as initial therapy in certain patients at high risk for fracture, such as older patients who have difficulty with the dosing requirements of oral bisphosphonates, patients unresponsive to other therapies and in those with impaired renal function.

Strontium ranelate can be used by women who cannot tolerate or are unable to take oral or intravenous bisphosphonates.

raloxifen is used for patients who cannot tolerate any bisphosphonates or for women with osteoporosis and increased risk of invasive breast cancer.

Other therapies:

Tibolon:

 Tibolone, a synthetic steroid whose metabolites have estrogenic, androgenic, and progestagenic properties and can be used for osteoporosis management.

Growth factors:

Only effective in patients with growth hormone deficiency.

Monitoring:

Health care practioners should monitor the patient for the following:

1.     Adherence to therapy

2.      Calcium and vitamin D levels

3.     DXA of hip and spine after two years, and continous monitoring according to response

4.    Biochemical markers including fasting urinary N-telopeptide (NTX) or serum carboxy-terminal collagen crosslinks (CTX) 

Cigarette smoking is the leading preventable cause of mortality. Smokers who stop smoking reduce their risk of developing and dying from tobacco-related diseases. To increase smoking cessation rates, patient’s smoking status should as assessed and documented in every visit

Behavioral counseling and pharmacotherapy produces the best results when combined together.  

Smoking status assessment:

Practioners should first assess the patient's tobacco use; including the duration of smoking history, the number of cigarettes smoked daily, and how soon after waking up the smoker has his first morning cigarette. More dependent smokers have smoked for many years, smoke more cigarettes daily, and smoke within the first 30 minutes of awakening.

The desire to stop smoking, and the history of previous quit attempts, the smoker's degree of nicotine dependence predicts the difficulty in quitting and the intensity of treatment needed.

Quitting barriers:

Smokers face several difficulties when they try to quit. The addictiveness of nicotine is the primary barrier.

Nicotine withdrawal syndrome:

In the absence of nicotine, a smoker develops cravings for cigarettes and symptoms of the nicotine withdrawal syndrome. These symptoms include:

• depressed mood
• Insomnia
• Irritability, frustration, or anger
• Anxiety
• Difficulty concentrating
• Restlessness
• Increased appetite or weight gain

These symptoms should be will known by practioners and patients so patients can know what to expect and how to deal with these symptoms.

Other barriers include daily activities associated with smoking like morning coffee, an alcoholic drink, or the end of a meal. These triggers contribute to the difficulty smokers have in smoking cessation.

Smoking cessation treatments:  

Behavioral counseling  

Behavioral counseling includes direct patient-clinician encounters, via telephone, computer programs, text messaging, or group-based therapy. The most intensive behavioral intervention acceptable to the patient should be offered. A simple five-step algorithm called the 5 A's (Ask, Advise, Assess, Assist, Arrange) helps you in remember counseling elements:

Most former smokers had to try to quit several times before they finally achieved success so the clinician should assess the smoker's previous experiences with attempts to quit. Assessing the methods that have been tried and the smoker's degree of success with each in order to guide recommendations for the next attempt.

The first step in Setting a quit plan is setting a quit date preferably within the next two weeks. Patients should be directed to stop smoking completely on their quit day and should be familiar with nicotine withdrawal symptoms and how to deal with it.

Some patients begin to reduce smoking in the days and weeks prior to the quit date. Also removing tobacco products from the environment and asking family and friends for support will increase smoking cessation rates.

Follow-up  — A follow-up visit should be scheduled within three to seven days of the patient's quit day to monitor response to smoking cessation therapy. Then patients should then be followed monthly for at least three months.  

Difficulty quitting and relapse 

When patients fail to stop smoking after the quit date, practioners should identify the cause of failure. Different reasons could contribute to this including high nicotine dependent, low self-confidence or little social support for quitting, not using medications optimally (eg, chewing nicotine gum too rapidly, failure of the medication to reduce nicotine withdrawal, or intolerance of medication side effects).

In this case you should remind your patients that they might need multiple attempts before they quit smoking permanently.

Always remember to ensure patient adherence and to intensify behavioral counseling.

Relapse prevention  

 Long-term follow-up is very important because even successful quitters can remain at high risk of relapse for several years after smoking cessation.

The clinician should encourage and congratulate the patient on quitting; simply asking how their lives have changed since they stopped smoking can highlight the benefits of smoking cessation. Also, it is important to know if the patient is facing any problems due to smoking cessation (eg, weight gain, depression, alcohol use) and to help him accordingly.

Management of relapse:

Smoker who are not ready to quit yet!

 For smokers who are not ready to quit, you have to assess the patient's motivation, benefits and risks in order to help the smoker to begin to think about quitting. A personalized message concerning a smoking-related health problem of the smoker himself or a family member may motivate some patients to quit smoking

Pharmacologic treatments:

First-line drug therapy for smokers includes

1.     Nicotine replacement therapy incuding nicotine gum, lozenges, spray and patches

2.     Buprobion

3.     Varenicline (champix)

Behavioral counseling in addition to pharmacological treatment when combined is better than either alone in increasing smoking cessation rates. The choice of pharmacological agent depends on patient preference, previous experience with the drugs, cost and medical conditions.

Light smokers: 

Behavioral counseling is the first line treatment for those who smoke 10 cigarettes per day or less.

Pharmacotherapy can also be used in light smokers who do not respond to behavioral counseling. The doses of nicotine replacement therapy, bupropion , and varenicline should be reduced for use in this population.