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Pulmonary hypertension in the elderly, part 2: TreatmentABSTRACT: The treatment of pulmonary arterial hypertension(PAH) is directed at the underlying cause, such as diastolicheart failure or chronic thromboembolic disease. Patients withidiopathic PAH or PAH associated with connective-tissue diseasewho have World Health Organization (WHO) functionalclass II or III PAH should receive a trial of oral bosentan, ambrisentan,and/or sildenafil; inhaled iloprost is an alternative oran additive agent. If patients fail to respond to these interventionsor if they have WHO functional class IV PAH, considersubcutaneous or intravenous treprostinil or epoprostenol. Theuse of these latter agents is much more complicated and maybe difficult to initiate in elderly patients. (J Respir Dis. 2008;29(12):468-474)
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Mesenteric Venous ThrombosisA 63-year-old man with a history of hypertension and gastroesophageal reflux disease presented with progressive, sharp mid-abdominal pain of 3 weeks' duration.
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Erythema ab Igne After Frequent Heating Pad UseA 62-year-old woman presented with a rash and intermittent pain of the right upper quadrant. The reticular, brown hyperpigmentation was also seen on her right flank and around the umbilicus. The patient reported that she often applied heating pads to these areas for pain relief.
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CARDIAC DRUG THERAPY (ed 6)In this compact clinical guide, the author presents detailed prescribing advice forall types of cardiac patients. The first chapters are devoted to the principal classesof cardiac drugs: β-blockers, angiotensin-converting enzyme inhibitors, angiotensinII receptor blockers, calcium antagonists, and diuretics. These chapterscover such topics as indications, contraindications, adverse effects, interactions,dosages, differences between the available agents in a given class, and how tochoose the most appropriate agent from a class for a particular patient. Chapterson the management of the various cardiac disorders-hypertension, angina, acutemyocardial infarction, heart failure, arrhythmias, cardiac arrest, infective endocarditis,and hyperlipidemia-comprise the core of the book. There are also chapterson antiplatelet agents, anticoagulants, and thrombin inhibitors; and the use ofcardiac drugs during pregnancy and lactation. The sixth edition features a newchapter on recent clinical trials, new American Heart Association cardiac arresttreatment algorithms, current hypertension management guidelines, and expandeddrug administration and dosage tables. Numerous tables, charts, algorithms,and graphs accompany the text.
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Osteomyelitis in a 75-Year-Old Heroin UserPresenting complaints were fever, nausea, and lower abdominal pain that worsened with walking. Osteomyelitis is not commonly included in a differential for abdominal pain. This case is different.
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Ophthalmic ZosterSeveral days earlier, a 69-year-old man had a mild headache, fatigue, and tingling and prickly facial sensations. Shortly afterward, this painful, “weepy” rash developed on his forehead, upper cheek, and nasolabial folds and vision in the right eye became blurry. The patient’s history included type 2 diabetes mellitus, hypertension, and childhood varicella.
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Bilateral Painless Swelling of the Neck in a 40-Year-Old ManOn palpation, the swelling was non-tender, soft, and mobile but did not feel fluid-filled. Here, view ultrasound findings and propose your diagnosis.
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Aquagenic UrticariaSwelling of the wrists and ankles of 3 months' duration prompted a 33-year-old man to seek medical attention. The swelling was highly migratory, with periods of regression that lasted several days at a time. The patient also had a 3-year history of "breaking out" after contact with water. He had no personal or family history of asthma, allergies, or other atopic disorders. He was not taking any medications.
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Asthma Disease Burden and Formulary Decision Making: MCO and Employer PerspectivesAsthma affects approximately 22 million adults and children in the United States and poses a significant economic burden on the health care system and on employers. According to the National Heart, Lung, and Blood Institute, direct and indirect costs for all forms of asthma totaled $19.7 billion in 2007. Prescription drugs represented the largest single direct cost at $6.2 billion.
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Fever and Rash: Infection or Kawasaki Syndrome?Kawasaki syndrome (KS) is a common and serious disorderthat most often affects children aged 1 to 8 years but mimicsa range of other diseases of childhood. Diagnosis of KS isbased on physical examination findings coupled with theexclusion of other causes. To provide optimal care for patients,it is important to be aware of the differential diagnosis of KS.We report a case of a 4-year-old boy who presented withpersistent fever and cervical lymphadenitis; later, mucousmembrane changes, rash, and conjunctival injectioncharacteristic of KS developed. [Infect Med. 2008;25:320-322]
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Acne ConglobataFor 3 months, a 24-year-old man-a military aviator-had a worsening rash on his chest. He had no lesions elsewhere. Culture of the ulcers grew Pseudomonas. A 2-week course of antibiotic therapy was ineffective.
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An Unusual Presentation of Septic HipEmphysematous cholecystitis is a rare condition that is the result of infection with Clostridium perfringens and other gas-producing organisms including Escherichia coli, Bacteroides fragilis, and Klebsiella species.
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Scrotal Calcinosis in Normocalcemic Primary HyperparathyroidismA 32-year-old man with no significant medical history presents with multiple scrotal lesions that he claims have been present for 2 years. They are non-tender and he reports no overt symptoms. The full case, here.
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Emerging Mold Infections: HyalohyphomycosisFilamentous fungi (molds) can be divided into 2 broad morphologically distinct groups: those that produce aseptate hyphae and those that produce aseptate (or rarely septated) hyphae. Identification of aseptate hyphae in tissue is virtually pathognomonic of zygomycosis (mucormycosis)-disease caused by fungi of the class Zygomycetes (order Mucorales). The discovery of septate hyphae in tissue is less diagnostic; septate hyphae may be caused by fungi that typically grow as yeasts (eg, Candida and Trichosporon) or a vast number of species of molds. The septate molds are often divided into those with darkly pigmented hyphae (phaeohyphomycetes) and those with pale or colorless (hyaline) hyphae (hyalohyphomycetes).
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Snake Bite: A Small Puncture Can Create a Large ProblemAn 8-year-old boy from southern Ohio was outside playing when he saw a snake lying in the driveway. The boy picked up the snake to show his father and then dropped it. He picked it up again and was bitten. He sustained a tiny puncture wound to the palmar aspect of his distal left ring finger and a scratch to the distal long finger.
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Atypical Tuberculin Skin Test ResponsesTuberculin-type hypersensitivity is characterized by marked spongiotic dermatitis with intraepidermal and subepidermal vesiculation and scattered eosinophils.
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Long-Term Efficacy and Safety of Tipranavir Boosted With RitonavirCritical ViewsinInfectiousDiseaseMedicine A
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Hemolytic Uremic SyndromeFor 24 hours, a 62-year-old woman had had severe weakness, abdominal pain, and watery diarrhea that had become bloody in the past 12 hours.She had no significant medical history.
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“Snakeskin” Gastric MucosaCirrhosis and ascites developed in a 52-year-old man with a history of chronic hepatitis C and alcohol abuse. He was hospitalized because of bleeding esophageal varices, which were successfully treated with elastic band ligation.
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COLONIC DISEASEAs the population ages, physicians are seeing a greaternumber of patients with colorectal disorders. This book combinesan up-to-date survey of the latest basic and clinicalresearch in the field with practical advice for the day-to-daycare of patients with colonic diseases. The first section ofthe book covers current knowledge of normal colorectal physiology.Section 2 discusses the basic disease mechanismsinvolved in colonic disorders and reviews the uses of suchinvestigational tools as colonoscopy, colonic biopsy, anorectalmanometry, ultrasonography, motility measurement,defecography, CT, and MRI. The third section offers a fulldiscussion of the diagnosis and treatment of commoncolonic disorders, including colorectal neoplasia, inflammatorybowel disease, ulcerative colitis, diverticular disease,Crohn disease, constipation, and irritable bowel syndrome.In addition to currently recommended approaches to evaluationand treatment, chapters in this section include discussionof advanced and investigational therapies.
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Bilateral Alien Hand SyndromeA 68-year-old woman was hospitalized because of confusion and agitation of sudden onset. Her history included dementia and multiple infarcts of both cerebellar hemispheres, bilateral basal ganglia, bilateral parietal lobes, and the right occipital lobe.
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Gastric Kaposi's SarcomaHIV infection was diagnosed in a 34-year-old man 3 years before he was hospitalized. The patient had a 2-week history of nausea; vomiting; and diffuse, intermittent, poorly localized abdominal pain. He had received radiotherapy and chemotherapy for Kaposi's sarcoma (KS) of the upper and lower extremities, which had been diagnosed 8 months earlier.
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Dog Bite in a 2-Year-Old BoyThe 2-year-old boy shown here had been bitten on the left cheek by a medium-sized dog while at the home of his day-care provider. Immediately after the incident, the child was examined by his pediatrician and given a presciption for amoxicillin clavulanate. The next day, he presented to the emergency department with worsening cellulitis of the left cheek.
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Ruptured Aortic AneurysmSevere abdominal pain radiating to the back prompted a 72-year-old man to go to the emergency department (ED). The patient had experienced similar pain 2 days earlier and was treated at another hospital for renal colic on the basis of concomitant microscopic hematuria. He had a history of poorly controlled hypertension.
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NSAID Nephrotoxicity Revisited:Selective COX-2 InhibitorsFor over 25 years, NSAIDs have been used to treat a variety of pain syndromesand inflammatory diseases. More than 50 million Americanstake these drugs. Unfortunately, control of pain and inflammation is notachieved without an associated cost-namely, GI complications and, to a lesserextent, nephrotoxicity.In an attempt to reduce drug-related toxicity, a new class of selectiveNSAIDs-the COX-2 inhibitors-was introduced in 1999. These selectiveNSAIDs are as effective as and pose less risk of gastric toxicity than nonselectiveNSAIDs.1,2The COX-2 inhibitors are thought to reduce end-organ injury, such as GIulceration, by sparing homeostatic or “constitutive” COX-1 enzyme function.1,2 Incontrast, therapeutic effects result from the inhibition of the “inducible” COX-2enzyme.1,2 Such drug effects target the production of proinflammatory prostaglandinsby COX-2 without interrupting normal cell function mediated by COX-1.2,3
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Drug-induced lung diseases: A state-of-the-art reviewp>Drug-induced lung disease (DILD) can be caused by a variety of agents, including chemotherapeutic drugs, antiarrhythmic agents, antibiotics, and NSAIDs. The clinical syndromes associated with DILD include alveolar hypoventilation, acute bronchospasm, organizing pneumonia, and hypersensitivity reactions. Amiodarone lung toxicity often manifests as a chronic fibrosing alveolitis, characterized by an insidious onset of cough, dyspnea, and weight loss. Important components of the workup include chest radiography, pulmonary function testing, and bronchoscopy with bronchoalveolar lavage (BAL). BAL is particularly helpful in identifying eosinophilic pneumonia and diffuse alveolar hemorrhage and in ruling out infectious causes. Management includes drug withdrawal and, in some cases, corticosteroid therapy. Before starting corticosteroids, it is important to rule out infectious causes of lung disease, particularly in patients receiving chemotherapy. (J Respir Dis. 2009;30(1))
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Renal Cell Carcinoma Metastases to the LungA 2-month history of cough sent a 62-year-old woman for medical evaluation. The patient denied fever, chills, and rigors but reported seeing streaks of blood in her sputum during the past month. The patient had undergone a right nephrectomy 4 years earlier for renal cell carcinoma.
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High-Calorie Diet Tied to Ca Risk for Some WomenAuthors of a new study were surprised to find that this relationship was exclusive to women of normal weight.
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Postpartum pulmonary arterial hypertensionPatients 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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ECG Changes in Polymorphic Ventricular TachycardiaTorsades de pointes, or polymorphic ventricular tachycardia, seen on ECG includes wide complex QRS morphology tachycardia, axis deviation of the QRS complexes around baseline.
