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A 75-year-old woman with a prior history of ischemic heart failure was referred for cardiology consultation for a heart murmur medicine 4212 discount 60 mg diltiazem with mastercard. Her physical exam revealed a displaced apex beat downward and to medications xyzal purchase diltiazem with american express the left and a holosystolic murmur loudest at the apex and radiating to symptoms 1974 cheap 60mg diltiazem the axilla medications 4h2 order discount diltiazem on-line. No differences exist between the two strategies in the incidence of major adverse cardiac and cerebrovascular events E. A short posterior leaflet is actually among the undesirable criteria for MitraClip. No differences in survival (option C is thus incorrect) or the incidence of major adverse cardiac and cerebrovascular events (option D is thus incorrect) were found. Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation. Prognostic significance of echocardiographically defined mitral regurgitation early after acute myocardial infarction. Surgical and interventional management of mitral valve regurgitation: a position statement from the European Society of Cardiology Working Groups on Cardiovascular Surgery and Valvular Heart Disease. Chronic ischaemic mitral regurgitation: exercise testing reveals its dynamic component. Long-term outcome of patients with heart failure and dynamic functional mitral regurgitation. The emerging role of exercise testing and stress echocardiography in valvular heart disease. Defining “severe” secondary mitral regurgitation: emphasizing an integrated approach. The American Association for Thoracic Surgery Consensus Guidelines: ischemic mitral valve regurgitation. The influence of postoperative mitral valve function on the late recurrence of atrial fibrillation after the maze procedure combined with mitral valvuloplasty. The Cox maze procedure in mitral valve disease: predictors of recurrent atrial fibrillation. Predicting recurrent mitral regurgitation after mitral valve repair for severe ischemic mitral regurgitation. The patient denied any symptoms such as exertional dyspnea, chest pain, or palpitations. A 56-year-old woman with no prior medical history was referred for cardiac consultation following a 6-month history of exertional dyspnea. Which of the following statements about this patient’s pulmonary hypertension is falsefi Secondary vasoconstriction in the pulmonary bed may play a role in its development B. The specific cause of the observed pulmonary vasoconstriction is well established C. The nitric oxide pathway may be involved in the mechanism of pulmonary vasoconstriction 50-4. A 19-year-old man with a prior history of acute rheumatic fever presented to the emergency department complaining of dyspnea on minimal exertion, orthopnea, and paroxysmal nocturnal dyspnea. Physical examination revealed a loud first heart sound and a low-pitched diastolic rumble best heard at the apex. The initial investigations, including a chest x-ray, were consistent with the diagnosis of pulmonary edema. A transthoracic echocardiogram was performed; it showed rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets, and a diastolic pressure half-time of 138 ms. A 55-year-old woman with a prior history of acute rheumatic fever at age 15 presented to the emergency department complaining of exertional dyspnea and intermittent palpitations. Which of the following would be the surgical treatment of choice for this patientfi A 49-year-old woman with no prior medical history presented to her cardiologist complaining of a reduced exercise tolerance. A 62-year-old woman with no prior medical history was referred for cardiac consultation following a 6-month history of exertional dyspnea and intermittent palpitations. Physical examination revealed an irregularly irregular pulse, a loud P2 and a middiastolic rumble. In addition, the assessment of the jugular venous pressure revealed absent “a” wave and “x” descent. Heart failure/pulmonary edema is a frequent finding, while atrial fibrillation is uncommon (option D is thus incorrect). This includes restrictions on physical activity (option B) and the use of beta-blockers (those with selective beta-1 activity is preferred). Metoprolol is preferred over atenolol because it has a lower incidence of intrauterine growth retardation 5 (option C). Hemodynamic effects of inhaled nitric oxide in women with mitral stenosis and pulmonary hypertension. Atrial fibrillation in pure rheumatic mitral valvular disease is expression of an atrial histological change. Favorable effect of balloon mitral valvuloplasty on the incidence of atrial fibrillation in patients with severe mitral stenosis. Usefulness of percutaneous balloon mitral commissurotomy in preventing the development of atrial fibrillation in patients with mitral stenosis. Real-time three-dimensional echocardiography for rheumatic mitral valve stenosis evaluation: an accurate and novel approach. A 15-year-old boy with a prior medical history of childhood murmur presented to the emergency department after a series of presyncopal episodes. The physical examination revealed a systolic ejection click, a loud systolic murmur peaking in late systole as well as a soft P2. An echocardiogram was obtained and showed doming and restricted opening of the pulmonary valve. In addition, spectral and color-flow Doppler revealed high-velocity turbulent flow in the main pulmonary artery consistent with pulmonary stenosis. A 19-year-old man with no known medical history presented to the emergency department complaining of flushing, diarrhea, and dyspnea. An echocardiogram demonstrated thickened barely mobile pulmonary valve cusps, with severe pulmonary regurgitation; subcostal imaging incidentally reveals a hepatic mass. An asymptomatic 47-year-old man with a remote history of rheumatic fever as a child is found to have a diastolic murmur during a routine physical examination; the murmur is best heard at the left lower sternal border and increases on inspiration. He is referred for an echocardiogram, which shows a thickened, distorted tricuspid valve with moderate tricuspid stenosis and mild-to-moderate tricuspid regurgitation. Which of the following statements regarding rheumatic tricuspid valve disease is falsefi Rheumatic involvement of the tricuspid valve is more common than the aortic valve B. Valve repair with balloon valvotomy or annuloplasty is preferred in cases where the valve is not severely distorted E. When valve replacement is needed, a bioprosthesis is preferred over a mechanical prosthesis 51-5. A 25-year-old woman with no significant past medical history was referred to the cardiology clinic complaining of a 6month history of exertional chest discomfort. The physical examination revealed a systolic murmur peaking in late systole and best heard over the pulmonary area, and a well-preserved but delayed P2. An echocardiography was obtained and showed normal pulmonary valve cusps, midsystolic cusp closure, a prominent presystolic a-wave, and a normal main pulmonary artery diameter. In addition, spectral and color-flow Doppler revealed a late-peaking, high-velocity flow with turbulence in the right ventricular outflow tract. A 19-year-old woman is followed in cardiology clinic for pulmonary valve stenosis, but she has missed her last appointments because she “felt fine. Four years ago, the physical examination revealed a systolic ejection click, a preserved but delayed P2, and a 2/6 systolic murmur peaking in early-to-mid systole that was best heard over the pulmonary area. Given the clinical suspicion of worsening pulmonary valve stenosis, which of the following physical examination findings would not be expected at this timefi
If you had any toothache or any jaw joint pain extremely (-1) in the last three months treatment definition math diltiazem 180mg free shipping, how much has this pain very much (-1) affected your sleepfi If you had any toothache or any jaw joint pain extreme (-1) in the last three months symptoms renal failure order 180 mg diltiazem with mastercard, how much stress has this very much (-1) pain caused youfi Have your teeth helped you to medicine xl3 buy diltiazem overnight delivery feel confident helped a lot (+1) during the last three monthsfi Have your teeth caused any embarrassment in extremely (-1) the last three monthsfi How satisfied have you been medicine keeper order 180mg diltiazem, on the whole, very satisfied (+1) with your gums in the last three monthsfi Have you felt any sensitivity when you ate or yes (-1) drank anything cold or acidic because your gums no (+1) retracted in the last three monthsfi The specific aims of the Oral Health Quality of life subproject are 1) to evaluate the impact of oral health and functional status on quality of life and 2) to model the relationship of “objective” and “subjective” measures of oral health and functional status to assessments of overall quality of life. Inclusion of the “subjective well-being” dimension of quality of life assessment complements traditional “objective functional status” measures, such as the Sickness Impact Profile1, which assess self-reported symptom frequency and functional impacts; thus, reestablishing the role of the personal or “humanistic” element into the quality of life equation. These selfreport measures ask about the frequency of oral health problems and their impact on a person’s ability to function in daily life. Happy NutQoL items measure the importance and satisfaction attributable to dietary habits like the daily consumption of fresh fruit and vegetables, taking daily vitamin supplements, and eating low fat meals. The initial items were administered to a systematic sample of N = 63 adult patients scheduled for dental diagnostic screening at the University of Texas Health Science Center Dental Clinic. Examination of item means and standard deviations flagged items that had little variability or were prone to floor and ceiling effects. Satisfaction responses are recoded as –2 = unhappy, –1 = somewhat unhappy, +1 = somewhat happy, +2 = happy. Thus, the subjective well-being items appear immediately following the related objective functional status items in the questionnaire. Several questions were added to smooth out transitions and trigger skip patterns in the interview. These summative scales measure problems with salivary function, taste, dental-facial aesthetics, oral-facial pain, speech, chewing and swallowing and global oral health. Our sample is further stratified into 6 age-decade strata ranging from 35-44 to 75+ years. The survey participants are members of two cohorts involved in the San Antonio Heart Study and the San Antonio Longitudinal Study of Aging. These results suggest that important ethnic group differences may exist in subjective assessments of oral quality of life, and that these differences are associated with dissatisfaction with dental-facial aesthetics and overall oral health. The three ethnic/language groups do not differ with respect to age, gender, or denture status. Eight scales are measures of oral health or functional status problems common to denture-wearers and non-denture-wearers: 1) salivary function, 2) taste, 3) sensory problems, 4) dissatisfaction with dental-facial aesthetics, 5) halitosis, 6) bleeding gums, 7) oral facial pain, and 8) chewing and swallowing difficulties. Another scale measures social problems with dentures, and is, therefore, applicable only for denturewearers. Another set of items measure self-reported oral hygiene behavior, and a final scale is comprised of items that measure an individual’s assessment of his or her overall oral health and functional status. The magnitude and significance level for the self-report indices are similar to those reported in the earlier studies. Cornell et al Oral Health Quality of Life Inventory units at risk (teeth or sites probed). It emphasizes the person’s assessment of the importance of oral health and functional status in his or her life, as well as his or her satisfaction with current oral health and functional status. This reduces the ambiguity inherent in such constructs as community, health, love relationships, etc. This context implicitly reduces some of the ambiguity that may accompany oral health related constructs. Taken together the “subjective well-being” and “objective functional status” may provide increased power to model the relationship between oral health and a person’s overall quality of life. Assessment of the subjective dimensions of importance and satisfaction with respect to oral health and function may also help explain some clinical phenomena. Patient compliance with oral hygiene and treatment may also be influenced by the subjective dimension. Quality of live assessment in therapeutic trials: Rationale for and presentation of a more appropriate instrument. Clinical Validation of the quality of life inventory: A measure of life satisfaction for use in treatment planning and outcome assessment. Cross-cultural adaptation of health-related quality of life measures: Literature review and proposed guidelines. For each statement, please give the answer that comes closest to saying what is true for you. How important is it to you not to have to stop what you are doing to get a drink of water because your mouth is dry: 1 Not at all Importantfi How happy are you with the number of times you have to stop what you are doing to get a drink of water because your mouth is dry: 1 Unhappyfi How important is it to you how your teeth or dentures look: 1 Not at all Importantfi How important is it to you to drink hot and cold liquids without pain: 1 Not at all Importantfi How important is it to you to be able to bite or chew hard foods such as nuts, apples, dried fruit, crunchy breads or rolls: 1 Not at all Importantfi How happy are you with your being able to bite or chew hard foods such as nuts, apples, dried fruit, crunchy breads or rolls: 1 Unhappyfi How important is it to you to be able to bite and chew food without pain: 1 Not at all Importantfi How happy are you with your being able to bite and chew foods without pain: 1 Unhappyfi How important is it to you to eat all your food without it sticking in your mouth (under your dentures; in your cheeks; on your tongue): 1 Not at all Importantfi How happy are you with your being able to eat all your food without it sticking in your mouth (under your dentures; in your cheeks; on your tongue): 1 Unhappyfi How important is it for you to swallow your food without choking or it getting caught in your throat: 1 Not at all Importantfi How happy are you with your being able to swallow your food without choking or it getting caught in your throat: 1 Unhappyfi The approach should provide advantages, not only in terms of being easier to measure the behavioral impacts on performances than the feeling-state dimensions, but also in being short. The first level refers to the oral status, including oral impairments, which most clinical indices attempt to measure. The second level, "the intermediate impacts", includes the possible earliest negative impacts caused by oral health status: pain, discomfort or functional limitation. Dissatisfaction with appearance was added in this level since studies indicated that it was a major dimension of oral health outcomes. The third level, or the "ultimate impacts" represents impacts on ability to perform daily activities which consists of physical, psychological and social performances. First, this approach makes the measure concise and yet covers the main consequences. Other concise indicators concentrate on some of the intermediate impacts in Level Two such as pain or chewing ability. Second, it helps to avoid, or at least reduce, overscoring from repeat scoring of the same impacts at each of the three levels. Third, only the significant impacts are recorded, by eliminating minor niggling conditions which do not lead to impacts on daily performances. Lastly, it is less difficult to measure the behavioral impacts, in terms of performance of daily activities. The reliability and validity of behaviorally-based measures are easier to establish. The nine physical, psychological and social performances were developed from the Comparison Table of Disability Indices8 and from various other sociomedical and sociodental indicators, to achieve content validity. Enjoying contact with people the Oral Impacts on Daily Performances index attempts to use the logical approach of impact quantification by assessing both frequency and severity. The criteria used for the description of both frequency (periodic pattern) and a spell period are modified from the questionnaire of the National Survey of Health and Development (Table Chapter 14. The basic guideline for the border line cases in differentiating between “regular” and “spell” pattern, is that the spell pattern is used for the case of less frequency of impacts than once a month.
J Clin Endocrinol Metab 2004; breastfeeding infiuence the risk of developing 89:4801–4809 Study 10-year follow-up medications that cause dry mouth buy diltiazem 180mg on line. American College of Obstetricians and Gybolic control and progression of retinopathy medicine 44175 buy discount diltiazem 60mg on line. National necologists; Task Force on Hypertension in diabetes and the incidence of type 2 diabetes: a Institute of Child Health and Human DevelopPregnancy symptoms uric acid buy diltiazem pills in toronto. Diabeof the American College of Obstetricians and 1862–1868 tes Care 1995;18:631–637 Gynecologists’ Task Force on Hypertension in 47 symptoms queasy stomach and headache order diltiazem with visa. Healthful dietary patMedicine; Food and Nutrition Board; Board on 1131 Children, Youth, and Families; Committee to Reterns and type 2 diabetes mellitus risk among women with a history of gestational diabetes 52. Arch Intern Med 2012;172:1566–1572 Less-tight versus tight control of hypertension Weight Gain During Pregnancy: Reexamining 48. J Obstet Gynaecol Can 2007;29: Care 2005;28:323–328 of gestational diabetes: effects of metformin 906–908 S120 Diabetes Care Volume 40, Supplement 1, January 2017 American Diabetes Association 14. B c Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold $180 mg/dL (10. C c Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fiuctuations and insulin dose. E c Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and correction components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake. A c Sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged. A c A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. E c the treatment regimen should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value is,70 mg/dL (3. C c There should be a structured discharge plan tailored to the individual patient with diabetes. B In the hospital, both hyperglycemia and hypoglycemia are associated with adverse outcomes including death (1,2). Therefore, inpatient goals should include the prevention of both hyperglycemia and hypoglycemia. Hospitals should promote the shortest, safe hospital stay and provide an effective transition out of the hospital that prevents acute complications and readmission. For in-depth review of inpatient hospital practice, consult recent reviews that focus on hospital care for diabetes (3,4). To correct this, hospitals have estabSuggested citation: American Diabetes Association. In lished protocols for structured patient care and structured order sets, which include Standards of Medical Care in Diabetesd2017. Because inpatient insulin use (5) and discharge orders for profit, and the work is not altered. More infor(6) can be more effective if based on an A1C level on admission (7), perform an A1C mationisavailableat. In addition, diabetes selfpersistently above this level may require porated into the day-to-day decisions remanagement knowledge and behaviors alterations in diet or a change in medicagarding insulin doses (2). Previously, In the patient who is eating meals, glutaking antihyperglycemic medications, hypoglycemia in hospitalized patients cose monitoring should be performed monitoring glucose, and recognizing has been defined as blood glucose before meals. A Cochrane review poglycemia is defined as that associated glucose monitoring that prohibit the of randomized controlled trials using with severe cognitive impairment regardsharing of fingerstick lancing devices, computerized advice to improve glucose less of blood glucose level (see Section 6 lancets, and needles (17). Electronic insulin order Moderate Versus Tight Glycemic questions about the appropriateness of templates also improve mean glucose Control these criteria, especially in the hospital levels without increasing hypoglycemia A meta-analysis of over 26 studies, inand for lower blood glucose readings in patients with type 2 diabetes, so struccluding the Normoglycemia in Intensive (18). Any glucose Appropriately trained specialists or speand mortality intightly versusmoderately result that does not correlate with the pacialty teams may reduce length of stay, controlled cohorts (16). This evidence estient’s clinical status should be confirmed improve glycemic control, and improve tablished new standards: insulin therapy through conventional laboratory glucose outcomes, but studies are few. More stringent goals, Even the best orders may not be carried such as,140 mg/dL (,7. However, in certain sole use of sliding scale insulin in the alogliptin in people who develop heart circumstances, it may be appropriate to inpatient hospital setting is strongly failure (31). If While there is evidence for using preglucagon-like peptide 1 receptor agooral medications are held in the hospital, mixed insulin formulations in the outnists show promise in the inpatient setthere should be a protocol for resuming patient setting (24), a recent inpatient ting (32); however, proof of safety and them 1–2 days before discharge. Moreover, the gasdue to potential blood-borne diseases, ble glycemic control but signifcantly introintestinal symptoms associated with and care should be taken to follow the creasedhypoglycemiainthegroup the glucagon-like peptide 1 receptor agolabel insert “For single patient use only. Therefore, nists may be problematic in the inpatinet premixed insulin regimens are not rousetting. Intravenous insulin infuavoided in severe illness, when ketone both hypoglycemia and hyperglycemia sions should be administered based on bodies are present, and during prolonged risks and potentially leading to diabetic validated written or computerized protofasting and surgical procedures (3). While hypoglycemia is associlin, a transition protocol is associated and human insulin result in similar glyceated with increased mortality, hypoglywith less morbidity and lower costs of mic control in the hospital setting (22). The use of subcutaneous rapidor diseaseratherthan the cause ofincreased A patient with type 1 or type 2 diabetes short-acting insulin before meals or mortality. However, until it is proven not being transitioned to outpatient subcuevery 4–6 h if no meals are given or if to be causal, it is prudent to avoid hypotaneous insulin should receive subcuthe patient is receiving continuous englycemia. Despite the preventable nature taneous basal insulin 1–2 h before the teral/parenteral nutrition is indicated to of many inpatient episodes of hypoglyceintravenous insulin is discontinued. Basal insulin mia, institutions are more likely to have verting to basal insulin at 60–80% of the or a basal plus bolus correction insulin nursing protocols for hypoglycemia treatdaily infusion dose has been shown to be regimen is the preferred treatment for ment than for its prevention when both effective (2,26,27). An insulin regimen with agement protocol should be adopted the correct dosing by utilizing an individual basal, nutritional, and correction comand implemented by each hospital or pen and cartrige for each patient, meticuponents is the preferred treatment for hospital system. There should be a stanlous pharmacist supervision of the dose noncritically ill hospitalized patients dardized hospital-wide, nurse-initiated administered, or other means (28,29). Current nutrition recommendainsulin should be divided into basal, nuinclude sudden reduction of corticostetions advise individualization based on tritional, and correctional components. Consistent with type 1 diabetes to ensure that they short-acting insulin in relation to meals, carbohydrate meal plans are preferred continue to receive basal insulin even if reduced infusion rate of intravenous by many hospitals as they facilitate the feedings are discontinued. One may dextrose, unexpected interruption of matching the prandial insulin dose to use the patient’s preadmission basal inoral, enteral, or parenteral feedings, the amount of carbohydrate consumed sulin dose or a percentage of the total and altered ability of the patient to re(40). Regarding enteral nutritional therdaily dose of insulin when the patient is port symptoms. In another study of hypoglycemic trition therapy, can serve as an individual ceiving continuous tube feedings, the toepisodes (,50 mg/dL [2. That person tal daily nutritional component may be 78% of patients were using basal insulin, should be responsible for integrating incalculated as 1 unit of insulin for every with the incidence of hypoglycemia formation aboutthe patient’s clinical con10–15 g carbohydrate per day or as a peaking between midnight and 6 A. Orders should also ally 50 to 70% of the total daily dose of of basal insulin changed before the next indicate that the meal delivery and nutriinsulin) Correctional insulin should also insulin administration (37). For papies including proactive surveillance of who successfully conduct self-management tients receiving continuous peripheral glycemic outliers and an interdisciplinary of diabetes at home, have the cognitive or central parenteral nutrition, regular data-drivenapproachtoglycemicmanand physical skills needed to successfully insulin may be added to the solution, agement showed that hypoglycemic self-administer insulin, and perform selfparticularly if. A starting dose of 1 unit of human such studies found that hypoglycemic proficient in carbohydrate estimation, regular insulin for every 10 g dextrose has events fell by 56% to 80% (38,39). The use multiple daily insulin injections or been recommended (44), to be adjusted Joint Commission recommends that all continuous subcutaneous insulin infusion daily in the solution. If self-management is to ance, the reader is encouraged to consult systemic issues. Once-aories to meet metabolic demands, opticluding the changing of infusion sites are day, short-acting glucocorticoids such mize glycemic control, address personal advised (42). For basal insulin plus premeal regular or cutaneous administration is used, it is long-acting glucocorticoids such as short-acting insulin (basal-bolus) covimportant to provide adequate fiuid redexamethasone or multidose or contineragehasbeenassociatedwithimplacement, nurse training, frequent uous glucocorticoid use, long-acting inproved glycemic control and lower bedside testing, infection treatment if sulin may be used (21,45). Target glucose range for the perialization based on a careful clinical and the individual patient may reduce length operative period should be 80– laboratory assessment is needed (51). Perform a preoperative risk assessof circulatory volume and tissue perfusion, fore, there should be a structured discharge ment for patients at high risk for ischeresolution of hyperglycemia, and correcplan tailored to each patient.
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In addition medications quizlet generic diltiazem 60mg on line, a dose-dependent association has been indicated medicine cabinet with lights cheap 60mg diltiazem amex, suggesting an additional beneft among those who attain an even higher activity level (29) treatment breast cancer purchase diltiazem 180 mg with amex. A Norwegian study (34) found that a single weekly bout of exercise of high intensity reduced the risk of cardiovascular death medicine news buy diltiazem online pills, both in men (~40%) and women (~50%), compared with those who reported no activity. In contrast to studies of male college graduates, in which mortality from ischaemic heart disease was gradually reduced with increasing energy expenditure from 500 to 3500 kcal per week (35), no additional benefts were found to be associated with as many as four high-intensity sessions per week compared with a single weekly bout (34). Some studies have suggested that physical activity and cardiovascular ftness have independent efects on overall mortality (36;37), but these associations appear to be complex. In one recent study, Lee et al (38) found that the preventive efect of following the guidelines for physical activity was completely attenuated when adjusting for ftness. This meant that the protective efect was confounded by high or low levels of ftness. In contrast, Hein and colleagues found that men who were inactive and highly ft had similar mortality rates from ischaemic heart disease as men who were inactive and unft, while men who were active and unft were protected compared to those who were inactive and unft (20). Although further studies are needed to examine the combined efects of activity 198 and ftness on morbidity and mortality and whether ftness modifes the association between activity and mortality, the scientifc evidence to date is consistent in suggesting that being physically active provides protection against all-cause mortality and cardiovascular disease regardless of ftness level. Increased physical activity has the potential to infuence all of these factors in a favourable manner at the same time. The “efect size” and the amount of physical activity needed to improve these factors are not fully understood, but some data in this regard are available for plasma lipids, blood pressure, and insulin sensitivity. The baseline levels of these metabolic risk markers strongly infuence the efect of physical activity, and greater benefcial efects are seen in those with poor lipoprotein profles. The improvements are probably more related to the amount of activity and not to the intensity of the activity or to improvement in cardiorespiratory ftness (40). A meta-analysis of randomised controlled trials has shown that the effect of exercise on systolic/diastolic blood pressure reduction is on average 3/2 mm Hg in normotensive and 8/6 mmHg in hypertensive individuals (41). Engaging in moderate intensity physical activity 3 to 5 times per week with a duration of 30–60 minutes appears to be efective in reducing blood pressure. There is strong scientifc evidence that regular physical activity has a benefcial efect on insulin sensitivity (42;46). Prospective studies have shown that regular physical activity brings about a linear decrease in the age-adjusted risk of developing type 2 diabetes (47–49). Importantly, the protective efect is also independent of general and central adiposity (50). The decrease in risk is on the order of 6% for each 500 kcal expended in physical activity during weekly leisure time (49). It appears that those who are at greatest risk of developing type 2 diabetes beneft the most from regular physical activity (48). Thus, regular physical activity is likely to be of importance in longterm regulation of body weight. However, there is limited evidence of a prospective association between physical activity and later body weight, and the association might be bi-directional. Regular physical activity is important for obese people because health benefts can be achieved through improved physical ftness regardless of whether or not weight loss occurs (53). The mortality and morbidity related to being overweight are substantially reduced in people who, despite being overweight, are physically ft (30;54;55). Only in short-term studies (16 weeks or shorter duration) is it possible to fnd evidence of a linear dose-response relationship between the amount of physical activity and the amount of weight loss when diet is controlled for. In practice, a weight loss of around 3 kg, with large individual variations, might be expected following increased physical activity in obese persons (57). Even though there is a lack of conclusive data, it seems that the amount of activity needed to avoid weight gain is about 60 minutes of moderate-intensity activity per day or a shorter duration if the activity is of vigorous intensity (58;59). Cancer Physical activity is an essential modifable lifestyle risk factor that has the potential to reduce the risk of some major forms of cancer (13;60). The risk reduction for active individuals is 10–70% for colon cancer, but this is dependent on intensity and duration (61). Physical activity might also prevent the development of endometrial cancer (62–64). The evidence is weaker for lung and prostate cancers and is generally either null or insufcient for all remaining cancers (63;64). There are several possible biological mechanisms through which physi200 cal activity might prevent cancer. They include, among others, the efect of physical activity on body composition and energy metabolism, insulin resistance, sex steroid hormones, infammation, and immune function. In a review by Fridenreich et al, it was estimated that between 9% and 19% of cancer cases in Europe can be attributed to lack of sufcient physical activity (64). They also found that public health recommendations for physical activity and cancer prevention generally suggest 30–60 min of moderateor vigorous-intensity activity performed at least 5 days per week. Recently, several observational studies, as well as some randomised clinical trials, have found that physical activity might improve survival in breast and colon cancer patients. However, the efects of physical activity on site-specifc cancer survival have not yet been fully established. Musculo-skeletal disorders Reversible risk factors for falls include weak lower limb muscle strength, poor balance, and a poor level of overall physical ftness, all of which can be improved by regular physical activity (65–68). Muscle strength and muscle endurance diminish with increasing age and decreasing activity level (69), and physical activity can counteract and reverse this trend to a substantial degree and keep older people independent in daily life longer (66;70). Physical activity contributes to increased bone density and can counteract osteoporosis, and physical activity immediately before and during puberty seems to yield greater maximum bone density in adult life (71–74). To be benefcial for bone mass and structure, exercise should preferably be weight-bearing (76) and repeated weight-bearing and loading, such as walking and running, is more benefcial than activities such as swimming and cycling. However, there is a lack of information about the dose-response relationship between activity/exercise and osteoporosis (76). Exercises that strengthen and stabilize the muscles of the back reduce the incidence of back problems. This is particularly true in people with a history of back problems, but these exercises are also efective to a certain degree among those who have not previously experienced such problems (77). Regular physical activity might have a preventive efect on lower back pain, but the type of the activity that has the most beneft has yet to be determined (76). There is also evidence that regular physical activity reduces symptoms of anxiety and poor sleep. Furthermore, observational studies have shown that those who are physically inactive are at greater risk of developing depression than those who are physically active (78;79). However, there is not enough data to determine clear-cut dose-response relationships between physical activity and depression and anxiety (80). There is evidence supporting the hypothesis that physical activity can prevent the development of vascular dementia (81) compared to a sedentary lifestyle. Further research is needed to study the volume and mode of physical activity that is most psychologically benefcial and to explore the mechanisms through which physical activity improves mental health. Several cross-sectional and prospective studies have demonstrated a relationship between sedentary behaviours, especially during leisure time, and obesity (81;82). Even in individuals fulflling the recommendations for physical activity, sitting for prolonged periods might compromise metabolic health (81). The underlying mechanisms are yet not fully known, but substantially decreased lipoprotein lipase activity as well as an instantaneously insulin-resistant state during sitting might contribute to adverse health efects (81). Energy expenditure difers substantially when comparing sitting still with standing, walking, or light intensity indoor activity (84), and a study from Australia showed that the frequency of breaks during prolonged sitting is associated with a favourable metabolic profle (85). Reducing sedentary time should be considered as an additional strategy in combination with the promotion physical activity 202 as a means of improving public health. Recommendations on physical activity There is strong evidence that vigorous intensity physical activity that is sufcient to improve cardiorespiratory ftness has a major impact on different health outcomes at all ages (12). In fact, previous recommendations on physical activity were equal to the quantity and quality of exercise suffcient to develop and maintain cardiorespiratory ftness. Therefore, it is important to emphasize that substantial health gains can be achieved through moderate intensity physical activity. Nevertheless, evidence from large population-based studies in healthy individuals (34, 87) demonstrates that physical activity with high intensity gives more robust risk reduction compared to that achieved by physical activity at low and moderate intensities.