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An 8-year-old boy was taken to his physician because of a rash around his mouth. After spending the day at the beach with his family, his lips had become red, itchy, and swollen. His sister had a similar, although milder, condition. Both children had been sucking on limes while at the beach. One week later, the boy experienced the chapped lips, patchy perioral erythema, swelling, and blisters.

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A 16-year-old Somali girl presents witha 3-day history of bilateral arm swellingand painful vesicular eruptions; hersymptoms are worsening. She reportsthat 5 days earlier, she and her friendshad used henna and black hair dyeto “tattoo” their skin. The others havenot experienced similar signs or symptoms.This patient has used henna(which is dark red) since childhoodfor decorative purposes. However, outliningan intricate design with hairdye is new for her.

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Most adult intussusceptions are caused by structural lesions, lead points for many of which are malignant neoplasms.

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Abstract: Multidrug-resistant tuberculosis is defined as tuberculosis caused by strains that have documented in vitro resistance to isoniazid and rifampin. Treatment involves a regimen consisting of at least 4 or 5 drugs to which the infecting strain has documented susceptibility. These agents may include ethambutol, pyrazinamide, streptomycin, a fluoroquinolone, ethionamide, prothionamide, cycloserine, and para-aminosalicylic acid. In addition, an injectable agent, such as kanamycin, amikacin, or capreomycin, should be used until negative sputum cultures have been documented for at least 6 months. If the patient has severe parenchymal damage, high-grade resistance, or clinically advanced disease, also consider clofazimine, amoxicillin/clavulanate, or clarithromycin, although there is little evidence supporting their efficacy in this setting. Routine monitoring includes monthly sputum smear and culture testing, monthly assessment of renal function and electrolyte levels, and liver function tests every 3 to 6 months. (J Respir Dis. 2006;27(4):172-182)

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Eosinophilic esophagitis is often misdiagnosed as gastroesophageal reflux disease but does not respond to acid suppression therapy. Here, a close-to-textbook case.

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A total of 50 health care professionals, including 25 health plan medical directors, 20 health plan pharmacy directors, and 5 pharmacy directors for pharmacy benefit management companies were surveyed regarding their perceptions of the value of 3 novel cancer therapies. The physicians and pharmacists were asked to estimate the monthly average wholesale price of each therapy, overall survival benefit of bevacizumab for treatment of persons with advanced colorectal cancer and erlotinib for treatment of persons with non–small-cell lung cancer, and progression-free survival benefit of sunitinib malate for treating persons with advanced renal cell carcinoma. Most respondents overestimated drug costs and underestimated survival benefit associated with these treatments. Mean incremental cost-effectiveness ratio for all drugs studied was approximately $170,000/quality-adjusted life-year (QALY). Cost-effectiveness ratios were lower than the $300,000/QALY cited by oncologists in another study but significantly higher than those for many other costly interventions. Our study findings reflect the need for a better understanding of the value of the clinical benefits of novel cancer therapies in an environment of product innovation but with resource constraints. (Drug Benefit Trends. 2009;21:120-130)

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The foundation of arterial blood gas (ABG) analysisconsists of determining whether the patient has acidosis or alkalosis;whether it is a respiratory or metabolic process; and,if respiratory, whether it is a pure respiratory process. If the patient'spH and PCO2 are increased or decreased in the same direction,the process is metabolic; if one is increased while theother is decreased, the process is respiratory. In a number ofclinical situations, pulse oximetry is preferred to ABG analysis.However, pulse oximetry may not be accurate in patients whoare profoundly anemic, hypotensive, or hypothermic. Whilevenous blood gas (VBG) analysis does not provide any informationabout the patient's oxygenation, it can help assessthe level of acidosis or alkalosis. VBG analysis may be particularlyuseful in patients with diabetic or alcoholic ketoacidosis.(J Respir Dis. 2008;29(2):74-82)

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The addition of basal insulin to current oral medication is the simplest way to initiate insulin therapy in patients with type 2 diabetes.

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A 16-year-old boy with a history of leukemia at age 12 years complains of right hip pain of several months' duration. A 34-year-old woman who had Hodgkin lymphoma at age 14 years comes in for a routine physical.

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For several days, a 50-year-old man has had copious green stools, vomiting, and fever. His symptoms began shortly after he was discharged from a regional burn center, where he was treated for full-thickness burns that covered 60% of his body surface.

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Abstract: Smoking cessation is still the most important intervention in patients with chronic obstructive pulmonary disease (COPD), regardless of sex. There is some evidence that nicotine replacement therapy may be less effective in women than in men. However, women may derive greater benefits from a sustained quit attempt. For example, one study found that compared with men, women who were sustained quitters had a greater initial rise and a slower age-related decline in forced expiratory volume in 1 second. Men and women do not appear to differ in their response to bupropion or to the various types of bronchodilators. A number of factors contribute to the increased risk of osteoporosis in women with COPD. Both smoking and the degree of airflow obstruction have been identified as important risk factors for osteoporosis. Women may be particularly susceptible to the effects of smoking on bone metabolism. Immobility and decreased physical activity have also been shown to accelerate bone loss. (J Respir Dis. 2006;27(3):115-122)

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A 12-year-old African American girl comes to youroffice for a well-child checkup. She is tall for herage (height above the 95th percentile) and obese(body mass index [BMI] above the 95th percentile).Physical examination reveals acanthosisnigricans on her neck, axilla, and upper abdominalregion (Figure) and a vaginal yeast infection.Routine urinalysis reveals a glucose level ofgreater than 1000 mg/dL, with negative proteinand ketones. A random blood glucose test, obtainedbecause of the glucosuria, is 249 mg/dL.

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Dr Schneider addresses myths and misunderstandings about the long-term use of opioids to treat noncancer pain.

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Nitrofurantoin has been widely used for the treatment and prevention of recurrent urinary tract infections since its introduction into clinical practice in 1953. Although it continues to be an effective antibiotic, nitrofurantoin is associated with several adverse effects, including pulmonary toxicity.

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Selective cyclooxygenase-2 (COX-2) inhibitors, such as celecoxib, rofecoxib, and valdecoxib, are an effective and commonly used class of drugs for the management of pain. They are particularly useful in patients who are unable to tolerate aspirin or traditional NSAIDs because of side effects.

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abstract: Pulmonary disease caused by nontuberculous mycobacteria (NTM) can be challenging to diagnose and manage. Patients typically present with nonspecific symptoms, such as cough and fever, and they often have underlying lung disease, which further complicates both diagnosis and treatment. To avoid treating pseudoinfection, the diagnosis should be based on a combination of the history and results of physical examination, radiographic imaging, and smears and cultures of at least 3 sputum samples. Occasionally, it is necessary to perform bronchoalveolar lavage or obtain tissue via transbronchial or open lung biopsy for histopathology and to assess for tissue invasion. Treatment involves a long course of often costly multiple antimycobacterial drugs. However, treatment with the second-generation macrolides, clarithromycin and azithromycin, has significantly improved cure rates for specific NTM infections. (J Respir Dis. 2007;28(1):7-18)

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Patients with congenital heart disease and pulmonary arterial hypertension (PAH) are at risk for severe deterioration during pregnancy and delivery. We discuss the case of a 38-year-old woman who presented to the emergency department complaining of dyspnea 6 days after giving birth to her first child via cesare- an section. When PAH is untreated, maternal mortality may exceed 50%, but aggressive PAH treatment offers improved outcomes. Moreover, initial improvement in functional status made with parenteral prostanoids can be maintained with combination oral therapy.

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ABSTRACT: Atypical clinical presentations in the quality, intensity, and radiation of pain are common in patients with acute coronary syndromes. Women with an acute myocardial infarction (AMI) are more likely to have atypical symptoms, such as dyspnea, than men. A history of acute anxiety or a psychiatric diagnosis does not preclude the possibility of an acute coronary event in a patient with chest pain. The clinical response to a GI cocktail, sublingual nitroglycerin, or chest wall palpation does not reliably identify the source of pain. Over-reliance on tests with poor sensitivity, such as the ECG, or on the initial set of cardiac biomarkers will miss many patients with MI. Serial troponin levels obtained at 3- to 6-hour intervals are recommended to evaluate the extent of myocardial damage. Coronary angiography that detects mild non-obstructive disease does not exclude the possibility of sudden plaque rupture and acute coronary occlusion.

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Rhabdomyolysis is linked to infection in up to 31% of cases. However, only 19 cases of rhabdomyolysis related to E coli infection have been reported.

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This 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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Metronidazole, the prototype nitroimidazole, was originally released in 1959 for the treatment of Trichomonas vaginalis infections. It has since been used to treat a variety of infections caused by anaerobic and facultative anaerobic bacteria and protozoa. Here we discuss the need for dosing adjustments in patients with hepatic disease.

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Progressive disseminated histoplasmosis (PDH) ismost likely to occur in patients with AIDS. Typical signs andsymptoms include fever, night sweats, anorexia, malaise, dyspnea,weight loss, hepatosplenomegaly, lymphadenopathy, skinlesions, and neurological deficits. The diagnosis of histoplasmosiscan be confirmed by tissue culture and stains and byserological studies. Bronchoscopy with bronchoalveolar lavage(BAL) often plays a pivotal role in the workup, particularly inpatients with respiratory symptoms and abnormal chest radiographicfindings. In some cases, transbronchial biopsy in conjunctionwith BAL can improve the diagnostic yield. Liposomalamphotericin B or amphotericin B lipid complex is recommendedfor the initial treatment of moderately severe to severePDH. Itraconazole may be appropriate for those with mild tomoderate PDH and is recommended for maintenance therapy.(J Respir Dis. 2008;29(1):37-40)

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Here: a review of the potential health effects of bed bugs, diagnosis and treatment, and comments about future directions in bed bug control and public health efforts to manage the pest.

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Ninety 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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A 6-year-old girl was evaluated in the emergency department for a leg rash that had spread to the buttocks. The lesions first appeared earlier in the day and worsened hourly. The child's mother reported that her daughter was in good health until a low-grade fever, nonproductive cough, sore throat, and headache developed 5 days earlier. The youngster also complained of neck pain with movement.

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A 68-year-old woman with a history of hypertension, hyperlipidemia, and tobacco use presented with her third stroke in the past 7 years. Neurological deficits included dysarthria and left-sided motor and sensory loss. A previous transthoracic echocardiogram with a bubble study did not reveal any cardiac source of embolism. Axial MRI of the brain on admission showed an abnormal signal in the bilateral hemispheres representative of multiple subacute infarcts

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A 23-year-old woman was referred to our interstitial lung disease (ILD) clinic with a diagnosis of LAM, a progressive cystic ILD that affects women of childbearing age. The patient had been a smoker since the age of 16, but she quit smoking about 2 months before the clinic visit, when she had a pneumothorax. At that time, she complained of sudden onset right-sided chest pain with shortness of breath for which she was admitted to her hometown hospital.

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Early diagnosis enables patients to derive maximum benefit from highly active antiretroviral therapy (HAART). Primary care practitioners can play a key role in the timely identification of HIV infection.

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