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Assessing the risk of crashes in patients with obstructive sleep apneaABSTRACT: Patients with obstructive sleep apnea (OSA) are at increasedrisk for motor vehicle crashes as a result of excessivesleepiness. However, a number of factors complicate risk assessment.For example, self-reported sleepiness and the severityof OSA do not appear to be good predictors of accident risk.Many persons with OSA do not accurately perceive their levelof drowsiness-self-reported sleepiness does not correlate wellwith objective measures, such as results of the Multiple SleepLatency Test. Moreover, it is not clear whether objective testscan reliably predict accident risk in the real world, as opposedto during simulated driving. The indications for-and benefitsof-restricting driving in patients with OSA have not been established.However, there is good evidence that the use of continuouspositive airway pressure significantly reduces the riskof crashes in these patients. (J Respir Dis. 2008;29(12):459-464)
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Exercise for Patients with Osteoarthritis: A Phased Approach to PlannngABSTRACT: Exercise can be an effective way to stabilize or slow the degenerative process of osteoarthritis-provided convenient, safe, and enjoyable activities are selected and achievable goals are set. Implement an osteoarthritis exercise plan in phases, and progress gradually from one phase to the next; this will help both you and your patient anticipate difficulties and gauge progress. The first phase-the initial evaluation-includes gathering baseline data, targeting an area of the body to focus on first, and identifying potential contraindications to activities. Subsequent phases include range of motion exercises (stretching), isometric and isotonic strengthening exercises, and recreational or functional activities. Encourage patients to continue stretching exercises throughout the program.
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Metastatic Squamous Cell CarcinomaShortly after arriving from Puerto Rico, a 59-year-old man presented with right-sided frontal head pain and decreased vision in his right eye. He was concerned about a “sore” that first developed 9 months earlier on his head. The patient denied fever, chills, and syncope.
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Bilateral Alien Hand SyndromeA 68-year-old woman was hospitalized because of confusion and agitation of sudden onset. Her history included dementia and multiple infarcts of both cerebellar hemispheres, bilateral basal ganglia, bilateral parietal lobes, and the right occipital lobe.
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Update on the Therapy for SporotrichosisSporotrichosis is a fungal infection that typically results in cutaneous or lymphocutaneous disease, although other, more severe, life-threatening manifestations do occur. This article reviews updated treatment guidelines, which state that itraconazole has become the preferred therapy for most forms of infection. Amphotericin B remains the mainstay of treatment for severe cases, but lipid formulations are now preferred because of their more favorable toxicity profile. Also, fluconazole has been shown to be less effective than itraconazole and is no longer recommended except as an alternative for cutaneous and lymphocutaneous disease. [Drug Benefit Trends. 2010;22:49-52]
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Hereditary Hemochromatosis: Early Detection of a Common Yet Elusive DiseaseAlthough widely regarded as a raredisorder, hereditary hemochromatosisis the most common genetic disease inCaucasians. In certain populations ofnorthern European descent, 1 of every200 persons is homozygous for thecausative mutation.1
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The technique of adult flexible bronchoscopy: Part 1ABSTRACT: Flexible bronchoscopy was clinically introduced byShigeto Ikeda in 1968 and is now used widely for diagnosticand therapeutic interventions. A combination of advancingtechnology and ingenuity has fostered the development of anexpanded array of devices and applications. The newer videobronchoscopes offer higher-resolution images than fiberopticbronchoscopes. The advantages of fiberoptic technology arelower cost and greater technical ease of adapting to smallerdiameterbronchoscopes. Hybrid bronchoscopes have an imaginglens and fiberoptic bundles that transmit the viewingimage to a charge couple device (CCD) chip in the body of theoperator end of the bronchoscope. The digital image is transmittedfrom the CCD chip to the external processor for viewingon a monitor, for digital storage, or for printing. (J Respir Dis.2008;29(11):423-428)
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Celiac Disease: Could You Be Missing This Diagnosis?ABSTRACT: Only a small number of patients with celiac disease exhibit the textbook symptoms of malabsorptive diarrhea with steatorrhea, weight loss, and nutritional deficiencies. Others may present with a subclinical enteropathy, GI complaints without constitutional symptoms, persistent travelers' diarrhea, or extraintestinal manifestations alone. Be alert for suggestive signs, such as weight loss, skin lesions, oral aphthae, muscle atrophy, de-enamelization of the teeth, and vague GI symptoms, such as bloating. Helpful serologic tests include IgG and IgA antigliadin antibodies, enzyme tissue transglutaminase antibodies, antiendomysial antibodies, and total IgA. Typical endoscopic findings are mucosal atrophy, fissuring, and scalloping. In addition to a gluten-free diet, management encompasses repletion of vitamins and minerals, including iron, folate, calcium, and vitamin D; screening for thyroid disease and diabetes mellitus; bone densitometry and age-appropriate cancer screening; and pneumococcal vaccination.
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West Nile Virus Infection: Are You Prepared?n the United States, the number of cases and geographic range of West Nile virus infection have increased since 1999, when the virus first surfaced in the Western Hemisphere. This year, the virus is expected to spread to all states except Alaska and Hawaii.
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Podcast: The Practice of Nonsuicidal Self-injury in Adolescents Part 2In Part 2 of this podcast series, Dr Smith continues his discussion of the practice of nonsuicidal self-injury in adolescents.
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Linear Verrucous Epidermal NevusA 7-year-old boy with a history of atopic dermatitis presented with an intensely pruritic linear rash on his upper extremity. His mother reports that the rash has been “growing” despite use of topical corticosteroid creams.
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Gastrointestinal Involvement of Systemic AmyloidosisThe authors present a case of AL amyloidosis with rare GI involvement and an equally rare presenting symptom.
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Creeping Eruption-Cutaneous Larva MigransCutaneous larva migrans (CLM), also known as “creeping eruption,” is the most commonly acquired tropical dermatosis
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Larsen SyndromeAn abnormality of both first proximal interphalangeal joints was noted in a 54-year-old woman who had recently undergone an elective total hip arthroplasty to treat post-traumatic osteoarthritis. She had had worsening hip pain following an intertrochanteric fracture and open reduction internal fixation several years earlier.
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Approved Treatments for Osteoporosis and What’s in the PipelineAlong with the release of revised guidelines, several pharmacological therapies have become available or are under investigation to help improve outcomes in patients with osteoporosis.
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COX-2 Inhibitor–Induced RashA 63-year-old man was given oral celecoxib, 100 mg bid, for shoulder pain. Three days later, a pruritic rash appeared on his back, then spread to the chest, lower legs, and face. He stopped the celecoxib on his own and self-administered diphenhydramine for the pruritus. The rash and itch persisted, which prompted the patient to seek medical care. He had no respiratory symptoms.
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Images in HIV/AIDS: HIV-Associated Lymphogranuloma Venereum ProctitisImages in HIV/AIDS: HIV-Associated Lymphogranuloma Venereum Proctitis
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Right Shoulder Pain in an Older ManFor 6 months, a 69-year-old man has experiencedpain in his right shoulder; hetakes NSAIDs for relief. During the lastmonth, the pain has worsened, weaknessand tingling have developed in his righthand, and the skin on the right side ofhis face has become dry. The patient alsoreports a 1-month history of melanoticstools. He had smoked 1 pack of cigarettesa day for 50 years before quittinglast year
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A Rare Finding of Lymphangiomatosis: Case ReportPatient was hemoccult positive with anemia but colonoscopy and EGD were negative. What test would you order next?
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Herpes Encephalitis in Monoclonal GammopathyNinety percent of adult cases of encephalitis are caused by herpes simplex virus (HSV) type 1, and HSV type 2 encephalitis is clinically indistinguishable from HSV-1 encephalitis.
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Greenfield Filter MigrationAn 82-year-old woman was admitted to the hospital with severe dilated cardiomyopathy. The condition was alcohol-induced and had been diagnosed about 12 years earlier. The patient was taking angiotensin-converting enzyme inhibitors and diuretics.
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Bilateral Parotid Swellings in an HIV-Positive PatientA large minority of persons with HIV infection have head and neck symptoms; parotid swellings have been noted in approximately 5% to 10% of patients with HIV-1 infection.
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MAC Infection in a Man With Pectus ExcavatumFor 6 weeks, a 56-year-old man had worsening dyspnea on exertion and a cough productive of yellow sputum with scant hemoptysis. He reported subjective fever over the past month but no weight loss.
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Enoxaparin DermatosisThis is a very distinct, rare, and remarkable hemorrhagic rash, first recognized in 2006, with 7 known cases reported in the literature.
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A Differential Diagnosis of Drug-Induced Aseptic MeningitisDrug-induced aseptic meningitis should be included in thedifferential diagnosis of viral/aseptic meningitis. Cliniciansshould use historical clues in patients presenting with signs andsymptoms of viral meningitis to aid in the differentiation ofdrug-induced aseptic meningitis from other causes of asepticmeningitis. Viruses are the most common cause of asepticmeningitis, with enteroviruses being the most common amongviruses in cases presenting as aseptic meningitis. Ibuprofen iscurrently the most common cause of drug-induced asepticmeningitis. Drug-induced aseptic meningitis is a benign conditionwithout long-term sequelae. The diagnosis of druginducedaseptic meningitis is made by establishing a causalrelationship between the use of the drug and the onset of signsand symptoms, supported by negative tests for infectiouscauses of symptoms and rapidity of resolution after the drugis discontinued. [Infect Med. 2008;25:331-334]
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Cocaine-Induced StrokeBrain infarcts among crack cocaine users may be secondary to large cerebral artery vasospasm with secondary intravascular thrombosis (with or without distal embolization).
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Emphysematous Pyelonephritis Caused by Pasteurella multocidaEmphysematous pyelonephritis (EPN) is a rare but life-threatening infection characterized by widespread necrosis and production of gas within the kidney.
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Women and Heart Disease: Incidence, Prevalence, Progress, and the FutureFemale CV mortality lags behind male mortality; lifetime risk assessment, not 10-year risk, is a better estimation tool for women
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Graves Disease with Exopthalmos and Pretibial MyexdemaThis 17-year-old presented with a 1-month history of weight loss, increased appetite, mild insomnia, hand tremor, palpitations, sweating, heat intolerance, and quick loss of temper. The number of daily bowel movements had increased from 1 to 2. There was no family history of thyroid disorders.
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Antimicrobial Resistance Update: Klebsiella pneumoniae CarbapenemasesThe rapid spread of Klebsiella pneumoniae carbapenemases (KPCs) is limiting the effectiveness of carbapenems in the treatment of multidrug-resistant infections. The resistance genes found in KPCs have been identified in other organisms as well and have properties that have raised concerns regarding their transmissibility and epidemic potential.
