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Cryptococcal cavitary pneumonia in an immunocompetent patientCryptococcus neoformansmost commonly infects personswith an underlying T-cellimmunodeficiency. It hasbeen nicknamed the "sugarcoatedkiller" because it cancause a devastating disseminatedillness in immunosuppressedpatients. C neoformansrarely causes primaryinfection in an immunocompetentpatient. We present acase of pulmonary cryptococcosisthat occurred in an otherwisehealthy man.
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Infant With a "Tail"A 6-cm midline tail-like soft tissue appendage was noted on the back of this newborn infant at the level of L5. An epithelialized mid-sacrum dimple was also present inferior to the appendage. The infant otherwise appeared to be normally developed.
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Invasive pulmonary aspergillosis, part 2: TreatmentABSTRACT: In general, the management of invasive pulmonaryaspergillosis is based on antifungal therapy and reversal of immunosuppression.Voriconazole is the preferred treatment inmost cases. Liposomal preparations of amphotericin B, caspofungin,and posaconazole are alternatives in patients whocannot tolerate voriconazole or have refractory aspergillosis.Prophylaxis in high-risk patients has gained popularity withthe availability of oral extended-spectrum azoles; posaconazoleis approved for prophylaxis in patients with acute leukemia,myelodysplastic syndrome, and graft versus host disease.(J Respir Dis. 2008;29(11):429-434)
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When should you suspect asbestos-related pulmonary disease?Abstract: A number of factors complicate the diagnosis of asbestos-related pulmonary diseases. Most persons who have had heavy exposure to asbestos are now aged at least 65 years and, therefore, are more likely to have other respiratory problems, such as chronic obstructive pulmonary disease, that may be difficult to differentiate from asbestosis. An accurate assessment of exposure history is particularly challenging because of poor recall of events by patients and because critical variables, such as fiber type, size, and length, can be difficult to evaluate. High-resolution CT (HRCT) has better sensitivity and specificity for asbestos-related pleural disease and neoplasms than does chest radiography. However, HRCT findings in patients with asbestosis are relatively nonspecific. Bronchoalveolar lavage and lung biopsy can provide definitive information about the extent of asbestos exposure. (J Respir Dis. 2005;26(11):499-510)
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Bacterial ArthritidesGonococcal infection is the leading cause of bacterial arthritis in adults.
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A Comparison of the Clinical Effectiveness and Cost-Effectiveness of Treatments for Moderate to Severe PsoriasisThis study investigated the clinical effectiveness and cost-effectiveness of treatments for moderate to severe psoriasis from a managed health care systems perspective. An analysis was conducted of randomized clinical trials evaluating biologic and oral systemic medications and phototherapy for patients with moderate to severe psoriasis.
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ChondrosarcomaA firm mass projected from the deltoid muscle region of a 24-year-old man's right shoulder.
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In Multiple Sclerosis, Motivational Interviewing Can Improve Exercise ExperiencePhysical inactivity is more common among patients with multiple sclerosis (MS) than the general public-even though studies have shown that exercise can reduce the frequency and intensity of MS symptoms. Here's a motivational technique that may help.
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Today's approach to the treatment of heparin-induced thrombocytopeniaAbstract: Failure to recognize heparin-induced thrombocytopenia (HIT) can lead to devastating thrombotic events, including pulmonary embolism and stroke. In most cases, the problem develops within 5 to 14 days after a first-time exposure to heparin. HIT can occur with either unfractionated heparin or low molecular weight heparin (LMWH), but the incidence is much lower with LMWH. When HIT is suspected clinically, a functional assay and immunoassay should be performed. However, treatment should not be delayed while waiting for laboratory confirmation. All forms of heparin should be eliminated, and treatment with an alternative anticoagulant should be initiated to prevent new thromboembolic events. Argatroban and lepirudin are the direct thrombin inhibitors that have been approved for the treatment of HIT. Because of the risk of warfarin-induced venous limb gangrene or skin necrosis, warfarin should be avoided in patients with acute HIT until their platelet counts have recovered and they are improving clinically. (J Respir Dis. 2006;27(6):248-259)
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Acute Gouty Arthritis and Gouty TophusA 5-day history of pain and swelling in the right third finger (A) were the complaints of a 76-year-old man. A few days earlier, another physician had prescribed indomethacin, 25 mg tid, but it had not helped, and the patient believed that his condition had worsened. He had had an attack of gout 5 years before but had not been taking any maintenance medication. The distal interphalangeal (DIP) joint of the affected finger was now erythematous and tender, with chalky subcutaneous deposits. A diagnosis of acute gouty arthritis and gouty tophus was made.
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Cystic Hygroma in a Young GirlA 21-month-old previously healthy child is brought to the pediatrician's office because of increasingly labored breathing that began the night before. The father reports that the child has had fever, congestion, nonproductive cough, and irritability for 2 days and that she is slightly hoarse.
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Mercury PoisoningA minimally responsive 26-year-old man was brought to the emergency department after being found in his home by a friend. A suicide note lay next to his body. The patient had a history of depression.
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Subclinical Hypothyroidism: REFERENCES: EvidencE-based medicine: Relevant guidelines:ABSTRACT: Subclinical hypothyroidism is associated with elevated low-density lipoprotein (LDL) cholesterol levels and several factors related to atherosclerosis, including increased C-reactive protein levels and impaired endothelium-dependent vasodilatation. However, considerable controversy exists about screening for and treating this thyroid disorder. Thyroxine therapy lowers elevated LDL cholesterol levels in patients whose serum thyroid-stimulating hormone (TSH) concentrations are higher than 10 mIU/L ; thus, most experts recommend treatment for such patients. However, there is no consensus regarding the management of patients with TSH levels of less than 10 mIU/L. Although the evidence supporting treatment of these patients is not compelling, it is reasonable to offer a therapeutic trial of thyroxine to those who have symptoms.
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Chronic Hepatitis C:The most common chronic blood-borne infection in the United States is caused by hepatitis C virus (HCV), an RNA virus transmitted through blood-to-blood contact. In this article, we identify risk factors for HCV infection and discuss which patients should be tested and treated.
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Various Manifestations of Rheumatic Disorders: Case 4 Idiopathic DermatomyositisA 76-year-old woman complained of progressive proximalmuscle weakness; achy pain in the buttocks, thighs, andcalves; and lilac discoloration of her eyelids, cheek, nose,knuckles, and fingernails.
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BlisterThis huge blister developed spontaneously on the foot of a woman withdiabetes mellitus. There was no area of redness around the blister, whichnormally occurs with burns and inflamed lesions. Spontaneous blisters andother skin manifestations are common in persons with diabetes.
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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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Emerging Treatments for Rheumatoid Arthritis:ABSTRACT: Early treatment with disease-modifying anti-rheumatic drugs (DMARDs)--alone or in combination-- can prevent joint damage and minimize disability. Until recently, the DMARDs used predominantly in patients with rheumatoid arthritis had been methotrexate, sulfasalazine, and hydoxychloroquine. Older DMARDs such as gold, d-penicillamine, and azathioprine have fallen out of favor because of their long- term toxicities or modest benefit. Six newer DMARDs--leflunomide, etanercept, infliximab, adalimumab, rituximab, and anakinra--have greatly expanded the current treatment options.
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Heterozygous Familial HypercholesterolemiaA 56-year-old woman was referred for management of severe hyperlipidemia. Her family history included hypercholesterolemia and premature coronary artery disease.
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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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Recurrent Epigastric Pain in an 82-Year-Old WomanAn 82-year-old woman who had recentlyarrived from Japan presented to theemergency department with a 3-dayhistory of abdominal pain that beganimmediately after she swallowed severalpills with a small amount of water.The severe, intermittent pain radiatedto the patient’s back and worsened withmeals. The patient denied chills, nausea,vomiting, coughing, diarrhea, andconstipation. She had well-controlledtype 2 diabetes mellitus and hypercholesterolemia,and had undergone anappendectomy 50 years earlier.
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Multiple Myeloma Presenting With CHFDyspnea, orthopnea, and weight loss sent a 40-year-old woman for medical consultation. Fifteen years earlier, the patient had been nephrectomized because of left kidney lithiasis. There was no history of other symptoms or diseases.
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What caused this woman’s pneumomediastinum?A 35-year-old woman presented to the emergency department (ED) with vague abdominal complaints. The patient had a complex medical history that included diverticulosis and relapsing polychondritis. Initially, her polychondritis was limited to involvement of the ears and nose. Within the past few years, however, her polychondritis flares had been associated with progressive dyspnea, which prompted intermittent and then long-term use of high-dose oral corticosteroids.
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Hypertension in African Americans:Uncontrolled hypertension is a major health problem among African Americans. Obesity, high sodium and low potassium intake, and inadequate physical activity have been identified as barriers to cardiovascular health in many African Americans. Thus, it is important to educate and counsel patients about lifestyle modifications, such as a low-sodium, DASH (Dietary Approaches to Stop Hypertension)-type diet; regular aerobic exercise; moderation of alcohol consumption; and smoking cessation. All classes of antihypertensive agents lower blood pressure in African Americans, although some may be less effective than others when used as monotherapy. Most patients require combination therapy. Both patient barriers (such as lack of access to health care and perceptions about health and the need for therapy) and physician barriers (such as poor communication styles) contribute to the low rates of hypertension control in African Americans. Patient-centered communication strategies can help overcome these barriers and can improve compliance and outcomes. Such strategies include the use of open-ended questions, active listening, patient education and counseling, and encouragement of patient participation in decision making.
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A Pregnant Woman With Lax Joints and SkinA 25-year-old woman presents for a prenatal visit. She has an unremarkable medical history except for hypermobility of the joints and a tendency to bruise easily. Her mother and sister also have very lax joints.
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PreventionHIV can be transmitted from an infected mother to her child during pregnancy or labor and postnatally through breast milk. Nearly 25 years after the first documented case of HIV infection, the decrease in perinatal HIV infections in the United States represents a major success in public health.
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ECCO: Circulating Tumor Cells May Aid in Breast Cancer PrognosisBARCELONA -- Monitoring circulating tumor cells in women with breast cancer may be help guide treatment and refine prognoses, according to preliminary data from German investigators.
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Anticoagulant Use Among Afib Patients Wanes Over TimeStudy results presented at the 2015 AHA meeting reinforce, once again, the critical role of persistent patient education on treatment adherence.
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Addressing Abuse and Misuse of Opioid AnalgesicsOpioid analgesics provide effective treatment for noncancer pain, but many physicians have concerns about adverse effects, tolerance, and addiction. Misuse of these drugs is prominent in patients with chronic pain. Recognition and early prevention of misuse helps physicians identify the causes and proceed with patient care. Most persons with chronic pain have a significant medical comorbidity (eg, asthma) that affects treatment decisions.
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Cecal Volvulus at an Unusual AgeFor the past 2 hours, a 19-year-old man had lower abdominal pain accompanied by nausea and vomiting. He had no fever and no diarrhea. Direct tenderness was mainly in the right lower quadrant, radiating slightly to the left lower quadrant. There was no significant rebound tenderness. The patient refused rectal examination.
