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Lowering the Bar: Love Potion Number 9 Million?Better living through science: reprinted from partner MedPage Today, this review looks at the "diseasification" of "low T" and "hypoactive sexual desire."
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Trump's Meeting with Wakefield Rattles Vaccine SupportersSome infectious disease specialists are anxious about the future of US vaccine policy; others are willing to suspend judgment, for now.
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Man With GI Symptoms and Weight Loss Attributable to Primary Duodenal AdenocarcinomaA 71-year-old man presents with a2-week history of early satiety, decreasedappetite, postprandial nauseaand vomiting, jaundice, dark urine,acholic stools, and generalized pruritus.In addition, he reports a 4.5-kg(10-lb) weight loss within the past2 months.
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Elderly Man With HypothermiaOn a warm August day, a 79-year-old man is hospitalized because of progressive lethargy over the past week. Previously, he was alert and able to converse. He has no chest pain, dyspnea, or cough. His history includes hypertension of unknown duration, chronic obstructive pulmonary disease, and a recent hospitalization for pneumonia.
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The Glycemic Index: How Useful Is It?Several popular diets, such as the South Beach Diet and Sugar Busters, are based on the glycemic index; however, many patients are confused about its significance.
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Biologics Are Changing the Face of Psoriasis TreatmentAs dermatologists' use of biologic drugs for psoriasis grows, MCOs must take an increasingly active role in managing the near-term utilization of these high-cost agents while also taking into account that some of the "payback" for these drugs comes in the form of long-term costs avoided. Meanwhile, physicians, insurers, and employers continue to wrestle with issues such as step-down dosing; step therapy; patient-administration versus physician-administration; and whether biologic drugs should be covered under a plan's pharmacy benefit, medical benefit, or some combination. (Drug Benefit Trends. 2008;20:143-147).
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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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West Nile VirusIt is high season for this potentially deadly viral infection, cases of which have been reported in every state. Will you be prepared? Guidance here from an expert.
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Pneumomediastinum After Emergent IntubationA 33-year-old woman with a history of severe asthma requiring multiple intubations was brought to the emergency department. She had completed a 14-day course of prednisone 3 days earlier. Since then, she had had increasing dyspnea that acutely worsened after she used her albuterol nebulizer that morning. Her other asthma medications were theophylline and fluticasone. Her history included one episode of bilateral pneumothoraces secondary to barotrauma, which required chest tube insertion.
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Allergic Rhinitis: Update on DiagnosisAllergic rhinitis is highly prevalent; about 20% of adults in the United States and 25% of children worldwide are affected. It is a major societal expense, with direct costs, attributable to physician visits and medications, of up to $5 billion per year, and indirect costs, mainly stemming from lost productivity, of up to $9.7 billion per year. In the United States, allergic rhinitis results in 3.5 million lost workdays and 2 million lost schooldays each year.
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Mucinous CystadenomaA 53-year-old perimenopausal woman presented to the emergency department with throbbing lower abdominal pain and distention. The pain started 5 days earlier and worsened with sitting and walking; she also experienced increasing dyspnea. She had noticed increasing abdominal girth about 5 months earlier. Since then, she had gained 5 to 10 lb, despite dieting. The patient reported a 22-pack-year history of smoking but no alcohol use. She was taking over-the-counter painkillers and allergy medications. Her family history was notable for a brother who died of laryngeal cancer.
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Disseminated Fusariosis Following Cutaneous Injury From Contact With a Palm TreeOpportunistic fungal infections are increasingly common inpatients who undergo hematopoietic stem cell transplant(HSCT). Voriconazole is frequently used in allogeneicSCT recipients who receive immunosuppressant therapy forgraft versus host disease to prevent invasive aspergillosis.Indications for voriconazole use include invasive aspergillosis,candidemia, Scedosporium apiospermum infection, and fusariosis.We describe a case in which disseminated Fusarium infectiondeveloped in an HSCT recipient who was receiving voriconazoletherapy. [Infect Med. 2008;25:528-530]
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Immunologic Idiopathic Thrombocytopenic PurpuraA mother, fearing that her 4-year-old son had been abused at his day-care center, rushed him to the emergency department, where an evaluation revealed a platelet count of 1,000/µL. Except for bruises on the boy's face and legs, the physical findings were normal. Bone marrow aspiration showed numerous megakaryocytes and was otherwise normal. The youngster's history included treatment for bronchitis, sinusitis, and conjunctivitis 2 weeks earlier.
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Caterpillar StingWhile playing on a brick walkway in her backyard, a 4-year-old girl stepped on a puss caterpillar and was stung. The ecchymosis exactly outlined the caterpillar's spines and remained visible for at least 3 months. The initial sting caused intense pain that lasted for more than an hour.
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Boerhaave SyndromeAn 85-year-old white woman was brought to the emergency department (ED) with acute, severe left posterolateral chest wall pain of several hours' duration. The nonradiating pain was accompanied by shortness of breath. She denied palpitations, diaphoresis, syncope, or dizziness.
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Abnormal Uterine Bleeding:Menstrual disorders are one of the most common complaints of women seen in primary care. Abnormal uterine bleeding (AUB) is a broad term that encompasses bleeding at abnormal or unexpected times or excessive flow at times of expected menses.
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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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Bipolar Disorder: How to Recognize and Treat in Primary CarePatients with psychiatric disordersoften present a diagnostic challenge-even for psychiatrists. Their demeanormay not readily reveal the nature orseverity of the problem. Nevertheless,there are clues that can help you sortthrough the differential and arrive atthe correct diagnosis.
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Psoriasis: Therapeutic OptionsTopical corticosteroids remain the mainstay of treatment, especially in patients with erythematous, acutely inflamed psoriatic plaques. The topical immunomodulators tacrolimus and pimecrolimus are used to treat psoriasis, although neither has FDA approval for this indication. Unlike corticosteroids, immunomodulators do not cause skin atrophy, irreversible striae, acne, or tachyphylaxis. Newer topical vehicles of delivery (eg, foam clobetasol propionate) and newer drug combinations (eg, once-daily calcipotriene/betamethasone dipropionate ointment) may improve efficacy and reduce side effects. Reserve systemic therapy for patients with moderate to severe psoriasis. Until more long-term safety data become available, be cautious about prescribing biologic agents for patients at risk for infection (particularly tuberculosis) and malignancy.
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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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Unseen Vector, Visible RashOn a tropical vacation, a woman develops a severe pruritic rash after being bitten on the hand by an insect. Can you name the bug?
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Life-Threatening Heart Failure Associated With ItraconazoleLife-threatening heart failure associated with itraconazoleantifungal therapy developed in a patient with disseminatedCoccidioides immitis infection. This was documented bycardiac studies that demonstrated a deterioration of cardiacfunction during therapy and an improvement after itraconazoletherapy was discontinued. Heart failure associatedwith itraconazole can be missed by those unfamiliar with thiscomplication. In any patient with a fungal infection who isbeing treated with itraconazole, this serious complication canoccur; however, it can be reversible with discontinuation ofthe drug. [Infect Med. 2008;25:292-293]
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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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Rebound Headache: Keys to Effective TherapyWhich of these scenarios is familiarto you? •A local pharmacist calls to say thatyour patient wants another refill for thecombination analgesic containing aspirin,caffeine, and butalbital that youprescribed last week. Pharmacy recordsindicate that this patient has received250 tablets of this medication inthe last 34 days.
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AspergillosisA 35-year-old HIV-positive man had a thick, black, otherwise asymptomatic patch on the top of his tongue. He did not have diabetes.
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Torus MandibularisDuring a new-patient evaluation, a 49-year-old Hispanic man was found to have several nontender, hard nodules protruding from the lingual area. The nodules had evolved slowly over several years. The patient reported no trauma to the area. He was a long-time smoker and took no medications. His medical and family histories were unremarkable.
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Lymphangioma CircumscriptumFor 10 years, a 22-year-old woman had had an erythematous, translucent patch of grouped blisters on her left thigh. A recent increase in the size of the patch prompted the patient to seek treatment. There was no burning or tingling at the site. The patient reported that the erythema occasionally cleared; however, the blisters always remained. She denied fever, weight loss, and other constitutional symptoms.
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Pulmonary Function Tests:ABSTRACT: Indications for pulmonary function tests (PFTs) have widened substantially, ranging from screening smokers for early lung disease to determining the diagnosis and prognosis of pulmonary conditions. Current indications also include screening for drug-induced lung toxicity and preoperative screening for lung resection surgery. In the workup of respiratory symptoms, such as dyspnea, cough, and wheezing, PFTs can identify obstructive or restrictive patterns that may suggest a diagnosis such as asthma or interstitial lung disease. The ratio of FEV1 to forced vital capacity is very sensitive to the presence of airflow limitation, although bronchoprovocation testing may be needed to diagnose asthma, especially in patients with mild intermittent disease. Measurements of lung volumes and carbon monoxide-diffusing capacity (DLCO) provide crucial information in selected patients. For example, a reduced DLCO may be a sign of more advanced disease, such as emphysema or pulmonary hypertension.Since the first description of the spirometer by John Hutchinson in the late 1800s, pulmonary function tests (PFTs) have expanded to include spirometry; lung volumes; carbon monoxide-diffusing capacity (DLCO) (transfer factor); respiratory muscle performance; and exercise and functional testing, such as the 6-minute walk test (6MWT) and cardiopulmonary exercise testing (CPET).
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Posaconazole: A New Triazole AntifungalPosaconazole, indicated for prophylaxis of invasive Aspergillus and Candida infections in immunosuppressed patients aged 13 years or older and for treatment of oropharyngeal candidiasis (Table 1), is like other triazole antifungals in that it blocks ergosterol biosynthesis. 1 Its chemical structure is most similar to that of itraconazole (Figure), which may confer efficacy even against strains resistant to fluconazole and voriconazole.2
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The Metabolic Syndrome: Early Clues, Effective ManagementThe metabolic syndrome represents a clustering of conditions and/or risk factors that lead to an increased incidence of type 2 diabetes mellitus and cardiovascular disease. These conditions include abdominal obesity, dyslipidemia, hypertension, insulin resistance, and a proinflammatory state.
