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A 38-year-old man presented to the emergency department after experiencing the sudden onset of right upper extremity numbness, heaviness, and loss of coordination, which resolved after 20 minutes. He had 2 similar episodes 19 years and 11 years earlier. Diagnostic evaluation (including MRI of the brain, carotid Doppler ultrasonography, and echocardiography) at the time of the second episode was unrevealing.

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A recent editorial in The New York Times heralded the conclusion, from 2 large sub-Saharan African studies, that male circumcision dramatically suppresses HIV acquisition rates as the "most important development in AIDS research since the debut of antiretroviral drugs."1 The editorial went on to state that while a "real [AIDS] vaccine is years away . . . we know its near equivalent [now] exists."1But Anthony Fauci, director of the National Institute for Allergy and Infectious Disease, was more circumspect. "These results could be negated by a small decrease in condom use or the addition of more sexual partners," he cautioned.2

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A 78-year-old woman requests evaluation of worsening dyspnea. A long-time smoker, she quit when chronic obstructive pulmonary disease (COPD) developed. At each of the last several visits, her hair had been uniformly white.

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This is a multisystem disorder characterized by oral and genital aphthae. Other symptoms include a myriad of cutaneous findings; variable systemic features include uveitis, synovitis, meningoencephalitis, and large- and smaller-vessel vascular disease.

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Low back pain is a widespread and costly complaint that affects virtually all Americans at some point in their lives. After the common cold, it is the second most frequent cause of work absence in the United States.

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A 15-day-old boy is brought for evaluation after his mother noted a "lump" in his left breast that morning. There is no history of illness or trauma. The infant's appetite and activities are normal, and he has no constitutional symptoms. He was delivered vaginally at full term and did not require a prolonged nursery stay or antibiotic therapy. Results of standard maternal screens were negative.

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A 62-year-old man presents with a violaceous, nonpruritic eruption that arose 2 weeks earlier on the hands and feet, including the palms and soles, and spread to the arms and legs (Figure 1). Over the past 3 to 4 weeks, he has had malaise, nonproductive cough, and a decline in mental status but no fever, headache, nausea, light-headedness, hemoptysis, or melena.

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Although many effective pharmacological therapiesare available for patients with allergies, only allergen-specificimmunotherapy has been shown to have significant and longlastingtherapeutic and immunomodulatory effects in the managementof allergic rhinitis, allergic asthma, and venom hypersensitivity.Standard allergen immunotherapy consists of subcutaneousinjections of relevant allergens. It requires a buildupphase during which the dose of the vaccine is increased until atherapeutic (maintenance) level is achieved. This maintenancedose is usually continued for 3 to 5 years, and most patientscontinue to do well after injections are discontinued. Most patientstolerate immunotherapy well, but local reactions are notuncommon. Immunotherapy should be administered only in aphysician's office, because some patients may experience systemicanaphylactic reactions requiring immediate therapy.Even with newer therapies on the horizon, allergen immunotherapywill continue to have an important role in the treatmentof allergic diseases. (J Respir Dis. 2008;29(3):136-141)

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Red imported fire ants (Solenopsis invicta) were introduced into the United States in the 1930s by ships from South America that docked in Mobile, Ala. Fire ants are now active throughout the southeast Sunbelt states. Colonies are also found in California; one of the largest is in Orange County.

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One in four people may cancel or delay surgery because the whole idea of general anesthesia is frightening. Offer good counsel to help keep things on track.

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Critical ViewsinInfectiousDiseaseMedicine A

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It is estimated that approximately 33.2 million persons worldwide were living with HIV infection in 2007.1 With the development of effective antiretroviral treatment strategies, HIV infection has now become a manageable chronic disease.2 Despite advances in treatment, drug resistance, long-term adverse effects, and high adherence requirements represent ongoing challenges to durable viral suppression.

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A 70-year-old woman with no previousmedical problems had had progressivedyspnea and generalized weaknessfor the past several days. She washypotensive (73/31 mm Hg), tachycardic(120 beats per minute), andtachypneic (28 breaths per minute);oxygen saturation (room air) via pulseoximetry was 84%.

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As the world of sport has embraced the participation of women and girls, the incidence of health problems that pertain specifically to premenopausal female athletes has increased significantly. One of these is the female athlete triad, which consists of 3 interrelated medical conditions associated with athletic training

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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.