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Management TrendsThe introduction of effective antiretroviral therapy has resulted in dramatic clinical benefits for those persons who have access to it. Adherence to such therapy has emerged as both the major determinant and the Achilles' heel of this success. Many patients have levels of adherence too low for durable virologic control.
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A 58-year-old man with facial flushing and dyspneaA previously healthy 58-year-old man presented to the emergency department with a 4-week history of gradually progressive dyspnea, facial flushing, and night sweats. Three weeks before presentation, he received the diagnosis of acne rosacea from an outside physician and was given topical treatments, with no relief in symptoms. One week before presentation, he began to notice swelling of the face, neck, and right arm and dysphagia (initially with solids, then progressing to liquids).
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Antidepressant-Induced Sexual Dysfunction: Five Management StrategiesSelective serotonin reuptake inhibitors and other second-generation antidepressants have become common therapeutic options for the management of depression. Although these agents are effective and generally well tolerated, they frequently cause sexual adverse effects that can impact patients’ quality of life, thus ultimately leading to nonadherence to therapy in many cases.
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Episternal OssicleAn 87-year-old woman was referred for a newly discovered neck mass. She denied any history of neck mass, dysphagia, odynophagia, stridor, shortness of breath, or globus sensation. She had experienced no change in voice.
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Hughes-Stovin SyndromeA 22-year-old man complained of progressive shortness of breath and abdominal distention. Three years before, he had completed chemotherapy for Hodgkin's disease and had since been in remission. Recently, he had been treated for tonsillitis with oral antibiotics.
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Recognizing the impact of obstructive sleep apnea in patients with asthmaAbstract: The coexistence of asthma and obstructive sleep apnea (OSA) in a given patient presents a number of diagnostic and treatment challenges. Although the relationship between these 2 diseases is complex, it is clear that risk factors such as obesity, rhinosinusitis, and gastroesophageal reflux disease (GERD) can complicate both asthma and OSA. In the evaluation of a patient with poorly controlled asthma, it is important to consider the possibility of OSA. The most obvious clues are daytime sleepiness and snoring, but the definitive diagnosis is made by polysomnography. Management of OSA may include weight loss and continuous positive airway pressure (CPAP). Surgical intervention, such as uvulopalatopharyngoplasty, may be an option for patients who cannot tolerate CPAP. Management may include specific therapies directed at GERD or upper airway disease as well as modification of the patient's asthma regimen. (J Respir Dis. 2005;26(10):423-435)
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Oral Contraceptives: Five Vignettes Illustrate Dx and Rx Problems-- and SolutionsOral Contraceptives: Five Vignettes Illustrate Dx and Rx Problems-- and Solutions
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Anaphylaxis Presenting as MacroglossiaThree days after having eaten fish, a 66-year-old woman with a known allergy to fish and a history of schizophrenia was brought to the emergency department because of macroglossia-a presentation of anaphylaxis. The patient refused airway management (intubation or cricothyrotomy) and was therefore admitted to the medical intensive care unit for monitoring of her airway and hemodynamic status. She received corticosteroids, ranitidine, diphenhydramine, epinephrine, and oxygen (via nasal cannula).
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Inflammatory Bowel Disease: 5 Things Primary Care Doctors Need to Know NowPatients with IBD may have discomfort for 3 to 5 years before a diagnosis is made. Many are treated unsuccessfully with antibiotics, anti-spasmodics, or narcotics. Here, read 5 important tips, plus a bonus point, to help streamline diagnosis and management.
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Use Peanut Butter to Sniff Out Early Alzheimer Disease?Peanut butter and a ruler may turn out to be tools that offer an inexpensive, sensitive, and specific olfactory means of screening for Alzheimer disease. Details here.
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An update on advances in interventional bronchoscopyAbstract: Because of recent advances, more patients may potentially benefit from a variety of interventional bronchoscopic techniques. Nd:YAG laser phototherapy is the most widely used modality and is the treatment of choice for patients with endobronchial malignancies who have large-central airway obstruction. Cryotherapy may be superior to Nd:YAG phototherapy for more distal airways lesions because of the lower risk of airway perforation, but it may be suboptimal for bulky airways disease that requires quick relief of obstruction. Brachytherapy relieves symptoms, such as cough, dyspnea, and hemoptysis, in many patients who have locally invasive airway malignancies. Endobronchial ultrasonography appears to be a safe and sensitive method for staging lung cancer. In select patients with emphysema, a 1-way endobronchial valve can be used to reduce lung volumes. Bronchial thermoplasty is being studied as a potential treatment for asthma. (J Respir Dis. 2006;27(10):415-428)
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An HIV-infected patient with bilateral pneumoniaA 43-year-old homeless woman presented with a 2-week history of fever, chills, sweats, generalized pain, and cough that was productive of purulent green-yellow sputum mixed with blood. She reported a 15-lb weight loss over the past 6 weeks.
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Superior Mesenteric Vein ThrombosisA 65-year-old woman with metastatic adenocarcinoma of the colon was undergoing chemotherapy following a colectomy and a hepatic wedge resection. The physical examination and laboratory data were unremarkable.
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Refractory Ulcer:What to Do Next?ABSTRACT: Undiagnosed or persistent Helicobacter pylori infection and surreptitious or unrecognized NSAID use are the most common causes of refractory peptic ulcers. The use of antibiotics, bismuth, or proton pump inhibitors (PPIs) suppresses the H pylori bacterial load and may obscure the diagnosis. H pylori infections have also become more difficult to cure because of increased antibiotic resistance. For refractory infection, select an antibiotic based on in vitro susceptibility testing. When this is not available, combination therapy with a PPI, tetracycline, metronidazole, and bismuth is often effective. To detect surreptitious or inadvertent NSAID use, review the drug history in detail. When there is any doubt about such use, check platelet cyclooxygenase function.
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Hypothyroidism and FibromyalgiaMonday morning your nurse hands you charts for 4 new patients. Each patient is a woman with widespread body pain, stiffness, and fatigue. All have already been evaluated by another physician and were advised that they should reduce stress and practice distraction techniques. They are in your office today seeking a second opinion.
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Lhermitte-Duclos DiseaseLhermitte-Duclos disease is a rare, slow-growing, benign lesion of the cerebellum and is considered a hamartomatous tumor of the cerebellar cortex.
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White Tongue Lesions: Candida, Contact Stomatitis, Oral Lichen Planus?Contact stomatitis can occur as a result of cinnamon exposure. The condition can easily be managed by withdrawal of the antigen. A short course of systemic corticosteroid can produce dramatic improvement if symptoms are severe.
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A Woman With Delirium From Diabetic KetoacidosisMucormycosis, an angioinvasive yeast infection of the Mucorales order of the class of Zygomycetes, often grows in patients with diabetes mellitus, especially in the presence of diabetic ketoacidosis.
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Yoga Practice Reduces Blood Pressure, Say Early ResultsYoga practice resulted in a 3-4 mm Hg decline in systolic BP at 24 weeks and a 2-3 mm Hg decline in diastolic BP on 24-hour ambulatory monitoring.
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Using Biomarkers to Guide Therapy, Coverage DecisionsIn August 2008, as part of its Critical Path Initiative, the FDA released a table listing genomic biomarkers that have established roles in determining drug response.1 This initiative, started in 2004, is aimed at identifying “patients likely to benefit from a treatment and patients more likely to respond adversely to a product,” according to the FDA’s Office of Management, Budget Formulation and Presentation.
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Polycystic Ovary Syndrome: When to SuspectABSTRACT: The key features of polycystic ovary syndrome (PCOS) are menstrual bleeding disturbances caused by chronic oligoovulation or anovulation and clinical or biochemical hyperandrogenism. The finding of polycystic ovaries on ultrasonography alone has limited predictive value. Obesity often coexists with PCOS and can exacerbate metabolic disturbances, particularly insulin resistance, but it is not a diagnostic finding. Laboratory results can rule out other conditions in the differential, such as an androgen- producing neoplasm, hypothyroidism, and late-onset congenital adrenal hyperplasia.
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Editorial Comment: Within Our Reach–The End of Perinatal HIV TransmissionThe elimination of perinatal HIV transmission in the United States is within reach. When antiretroviral therapy is effective in controlling maternal viremia during pregnancy, the risk of perinatal transmission is less than 1%.
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Healthful Eating Habits, Cancer, and Heart DiseaseThe authors of the Women’s HealthInitiative (WHI) study involving50,000 postmenopausal women concluded thata low-fat diet (goal: 20% of total calories) had no significant effect on the incidence of breast cancer, coloncancer, or heart disease. What should we be telling our patients?
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Long-Term Efficacy and Safety of Tipranavir Boosted With RitonavirCritical ViewsinInfectiousDiseaseMedicine A
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Clinicians Wait for Next Wave of Hepatitis C AntiviralsOne expert calls it "HIV all over again," but the revolution in hepatitis C treatment has taken place more quickly. And the new drugs act more quickly and effectively.
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Experts Consider Life-saving Potential of VapingA predictive model that replaces cigarette smoking with vaping projects nearly 21 million fewer life-years lost.
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Herpes Zoster in Multiple DermatomesA 50-year-old woman had visited 4 health care providers seeking relief from low back pain. The patient likened the pain to an electric shock that started at the left side of the lower back and radiated to the front of the left leg. The area was also numb.
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Apical Ballooning SyndromeAfter a family argument, an 83-year-old woman experienced chest pain, a "racing heart," and a choking sensation and was brought to the emergency department. The chest pain lasted 10 to 15 minutes; was sharp, substernal, and nonradiating; and was associated with dyspnea and a bout of emesis. A sublingual nitroglycerin tablet partially alleviated the pain, but the patient felt syncopal. Her symptoms persisted despite the administration of supplemental oxygen and a second sublingual nitroglycerin tablet. The patient had a history of gastroesophageal reflux disease, allergic rhinitis, and osteoarthritis. Her oral medications included esomeprazole (40 mg/d), aspirin (81 mg/d), and fluticasone nasal spray. She had discontinued valdecoxib 3 weeks earlier.
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Progressive DyspneaA 37-year-old woman presented with progressive dyspnea of 2 weeks' duration, a low-grade fever, and night sweats. She had been a healthy marathon runner until her exercise tolerance recently declined.
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Podcast: Bariatric Surgery Bests Medical Therapy Alone in Obese Patients with DiabetesBariatric surgery nearly cures type 2 diabetes-at least that’s what results of a new study, presented at the recent ACC meeting, seem to imply.
