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Policy Watch: Using Science, Abusing Science

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Many patients clearly would benefit from help from clinicians, but two-thirds of patients have never sought medical care for this disorder.

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Topical steroids and antifungals have not only failed to resolve the bilateral rash; the teen says they’ve made it worse. Your Dx?

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INDIANAPOLIS -- Each person metabolizes food differently, so the diet that works for one person won't work for another.

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After 5 weeks of undulating fever, weight loss, and night sweats, a 22-year-old man presented to the emergency department. He reported no significant medical history. The patient had recently completed a course of tetracycline followed by another of azithromycin for a presumed upper respiratory tract infection.

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A 23-year-old woman presents withweight loss, epigastric pain, abdominalfullness, and mild nausea. Shereports that she has had a slow-growingmass on her upper middle abdomen.She denies vomiting and doesnot have evidence of jaundice. Theonly significant finding in her medicalhistory is a myringotomy performedmany years earlier. She currentlytakes an oral contraceptive.

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A 38-year-old woman presented with bruising and pain of the lower extremities and dyspnea on exertion. She had had these symptoms for 3 weeks. She denied hematuria, melena, hematemesis, fever, or abdominal pain. Results of routine blood work showed a hemoglobin level of 6.4 g/dL (19 months earlier, this level was 15.8 g/dL).

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A 66-year-old woman was hospitalized because of severe anemia secondary to myelodysplastic syndrome. She had had associated fatigue and throbbing pain in both legs for several days.

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Specialty medications constitute the fastest-growing segment of drug spending under the pharmacy benefit. This study evaluated the impact of a specialty pharmacy prior authorization (PA) program on prescription drug costs for biologic response modifiers (BRMs) used in the treatment of persons with rheumatoid arthritis, juvenile rheumatoid arthritis, Crohn disease, ankylosing spondylitis, psoriatic arthritis, psoriasis, and other spondyloarthropathies. A retrospective, case-control, one-to-one matching approach based on patient age, sex, and client characteristics was used. Case clients were enrolled in the specialty pharmacy PA program from January 1 through December 31, 2005. The control group consisted of clients who were not enrolled in the program during this time. The average costs per eligible member per month (PMPM), for the total, plan, and member were $1.32, $1.29, and $0.03, respectively, in the case group, and $1.44, $1.41, and $0.03, respectively, in the control group. Clients who implemented the specialty pharmacy PA program for BRMs saved an estimated total cost of $0.12 PMPM. Implementing a specialty pharmacy PA program reduced BRM costs. (Drug Benefit Trends. 2008;20:26-31)

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A39-year-old man with a history of AIDS and nonadherence to highly active antiretroviral therapy (HAART) presented with frontal headache and scalp pain of 2 weeks' duration. These symptoms were accompanied by nausea, weight loss, and generalized weakness. Physical examination revealed a small, tender scalp lump, 2 × 2 cm over the left parietal area. The findings from the rest of the examination were unremarkable.

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For 2 weeks, a 31-year-old man has had a nonhealing, painful abscess on his left shoulder. A week before presentation, he sought treatment at a walk-in clinic; the abscess was incised and drained, and he was given gatifloxacin.

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For 3 weeks, a previously healthy 24-year-old man had repeated episodes of nonbloody, nonbilious emesis. He denied dysphagia, but he did report a 40-lb (18-kg) weight loss and heartburn.

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abstract: Pulmonary alveolar proteinosis (PAP) is characterized by the accumulation of lipoproteinaceous material in the alveoli. The most common symptoms are dyspnea on exertion and nonproductive cough. Weight loss, fatigue, chest pain, and hemoptysis have also been reported. Chest radiographs typically show bilateral, symmetrical airspace disease with an ill-defined nodular or confluent pattern, which gives a "bat wing" appearance, as is seen in heart failure. Pulmonary function tests usually demonstrate mild restrictive disease. Findings on examination of sputum specimens or bronchoalveolar lavage fluid can suggest the diagnosis; however, open lung biopsy is the diagnostic gold standard. Whole lung lavage remains the standard of care for PAP and is warranted in patients with severe dyspnea and hypoxemia. Subcutaneous human recombinant granulocyte-macrophage colony-stimulating factor appears to be a promising alternative to whole lung lavage for symptomatic patients. (J Respir Dis. 2007;28(5):177-184)

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Leukemia, brain tumors (glioma, medulloblastoma), and neuroblastoma constitute the most common types of childhood cancers.

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A 14-year-old boy presented with a 3-day history ofrunny nose, cough, and fever. His temperature was37.7°C (100ºF); heart rate, 78 beats per minute; and respirationrate, 26 breaths per minute. Several symmetric,circular ecchymotic lesions that measured 4 cm in diameterwere noted on the upper chest. There was no evidenceof external injury to other parts of the body. Thechild reported that the bruises resulted from cupping,performed by a Chinese practitioner in an attempt torelieve the fever.

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Abstract: Patients who have aspirin-exacerbated respiratory disease (AERD) usually experience upper and lower respiratory tract symptoms about 1Z|x to 2 hours after taking aspirin or another NSAID that inhibits the enzyme cyclooxygenase-1. In addition to symptoms such as nasal congestion, rhinorrhea, paroxysmal sneezing, periorbital edema, laryngospasm, and intense flushing, patients may have severe--often life-threatening--exacerbations of asthma. AERD occurs in about 10% to 20% of patients with asthma and in about 30% of asthmatic patients with nasal polyposis. However, AERD also occurs in patients who do not have any of these predispos- ing conditions. In patients with AERD, aspirin desensitization can improve asthma control, reduce the need for corticosteroids, and reduce the need for sinus surgery. (J Respir Dis. 2006;27(7):282-290)

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A 52-year-old man with hypertension and hyperlipidemia presents to the emergency department with a 5-month history of cough and dyspnea.

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The 25% reduction in relative risk seen in patients treated to 120 vs 140 mm Hg corresponds to an absolute risk reduction of 1.6%.

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When parents play out worst case scenarios in protest against routine vaccination, maybe one or two of these 6 options for response will come in handy.

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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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abstract: Tuberculous pericarditis, while relatively rare in the United States, is an important cause of pericardial disease in countries where tuberculosis is prevalent. Patients are most likely to present with chronic disease--effusive and/or constrictive. Those with effusive pericarditis often present with tamponade. Patients with constrictive pericarditis exhibit features of systemic and pulmonary venous congestion. An elevated level of adenosine deaminase in pericardial fluid is a good marker for tuberculosis. The presence of granulomas or case-ation necrosis in pericardial tissue confirms the diagnosis. If treatment of effusive tuberculous pericarditis is delayed, constrictive or effusive-constrictive disease usually develops, resulting in a high mortality risk. In addition to a standard antituberculosis regimen, treatment of tuberculous pericarditis may include adjuvant therapy with corticosteroids, pericardiocentesis, and/or pericardiectomy. (J Respir Dis. 2007;28(7):278-282)

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A 62-year-old woman was seen prior to cholecystectomy. She had no cardiac or pulmonary disorders. Examination was unremarkable other than a purplish-reddish, lace-like pattern on the thighs and forearms.

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What happens when complementary and alternative therapies are combined with traditional treatments in patients with multiple sclerosis? A new study suggests some positive benefits. Details here.

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Here: a project that sheds some light on the potential of an integrated and holistic approach to therapy for patients with multiple sclerosis.

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Community-acquired pneumonia is a frequent cause ofhospital admission in adults. It usually results from infectionwith pathogens such as Streptococcus pneumoniae, Haemophilusinfluenzae, Mycoplasma, and Chlamydia, among others. In a fewcases, pneumonia develops from infection with unusualpathogens, such as Pasteurella multocida, a gram-negativeorganism commonly found in the mouths of cats and dogs.We report a case of P multocida pneumonia associated with skintrauma caused by cat scratches in a woman with a history ofchronic obstructive pulmonary disease. [Infect Med. 2008;25:487-489]

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ABSTRACT: A thorough history and physical examination can establish the diagnosis of tension headache; further evaluation is generally unnecessary. In contrast, the workup of cervicogenic headache includes standard radiographs, 3-dimensional CT, MRI, and possibly electromyography; nerve blocks may also be used to confirm the diagnosis. Episodic tension headache can be treated effectively by trigger avoidance, behavioral modalities, and structured use of analgesics. Reserve opioids for patients with intractable headaches. Chronic tension headache is treated primarily by prophylactic measures, such as antidepressants and anticonvulsants, and behavioral and physical therapy. Treatment options for cervicogenic headache include analgesics; invasive procedures, such as trigger point injections, greater or lesser occipital nerve blocks, facet joint blocks, segmental nerve root blocks, and diskography; spinal manipulation; and behavioral approaches.

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Green discoloration of the fingernailsdeveloped 6 weeks after a 29-year-oldwoman had artificial nails placed duringa manicure. The patient was a doctorof pharmacy degree candidate whowas married and had 2 children.

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A woman has white, numb, cold hands after vigorous exercise, emotional stress, and exposure to cold. Is this caused by Buerger disease (thromboangiitis obliterans), acute arterial occlusion, Raynaud disease, or acrocyanosis?

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Levothyroxine is one of the most commonly prescribed medications for the treatment of persons with hypothyroidism and the suppression of thyroid neoplasms.1 Most persons with hypothyroidism require lifelong therapy with levothyroxine.