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abstract: In the treatment of certain allergies, sublingual immunotherapy (SLIT) may represent an attractive alternative to subcutaneous immunotherapy (SCIT) because of its lower risk of systemic reactions. The most common adverse reactions are local symptoms, such as oral "itchiness." GI complaints, rhinoconjunctivitis, urticaria, and asthma are uncommon reactions to this therapy, and no fatalities have been reported. In contrast to SCIT, accelerated induction schedules for SLIT do not appear to be associated with an increased risk of systemic reactions. SLIT may present an opportunity for broadening the use of immunotherapy by extending it to patients who are not candidates for SCIT because they dislike injections, find the frequent visits to the physician's office inconvenient, or are concerned with the safety of SCIT. The optimal effective dose and dosing schedule need to be established before a cost-benefit analysis can be performed. (J Respir Dis. 2007;28(6):237-243)

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Abstract: A number of factors can contribute to a delay in the diagnosis of tuberculosis in pregnant women, including the presence of nonspecific symptoms, such as fatigue and cough; extrapulmonary manifestations; and asymptomatic disease. The diagnostic evaluation is the same as for nonpregnant patients and includes tuberculin skin testing and, when indicated, chest radiography (with appropriate shielding) and acid-fast bacillus stain and culture. Antituberculous therapy during pregnancy is generally safe and effective, although streptomycin should not be used because of the risk of vestibular or auditory damage to the fetus. For patients with active tuberculosis, treatment should be initiated as soon as the diagnosis is established. The treatment of latent infection is somewhat more controversial. The timing of the initiation of therapy is based on the risk of progression to active disease. (J Respir Dis. 2006;27(8):338-347)

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A 14-year-old girl came to the officewith severe hip pain, which occurredafter she attempted a cheerleadingmaneuver on a trampoline. She reportedthat she was bouncing as highas she could and landed on the trampolinewith her left knee flexed andher right hip extended. On impact,she felt a “pop” that was immediatelyfollowed by right hip pain.

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Images in HIV/AIDS: HIV-Associated Lymphogranuloma Venereum Proctitis

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Uncontrolled hypertension is a major health problem among African Americans. Obesity, high sodium and low potassium intake, and inadequate physical activity have been identified as barriers to cardiovascular health in many African Americans. Thus, it is important to educate and counsel patients about lifestyle modifications, such as a low-sodium, DASH (Dietary Approaches to Stop Hypertension)-type diet; regular aerobic exercise; moderation of alcohol consumption; and smoking cessation. All classes of antihypertensive agents lower blood pressure in African Americans, although some may be less effective than others when used as monotherapy. Most patients require combination therapy. Both patient barriers (such as lack of access to health care and perceptions about health and the need for therapy) and physician barriers (such as poor communication styles) contribute to the low rates of hypertension control in African Americans. Patient-centered communication strategies can help overcome these barriers and can improve compliance and outcomes. Such strategies include the use of open-ended questions, active listening, patient education and counseling, and encouragement of patient participation in decision making.

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Persons with severe mental illnesses (SMI), such as schizophrenia, are at increased risk for comorbid conditions- including type 2 diabetes-independent of therapy. SMI sufferers especially at risk for type 2 diabetes are women, African Americans, and persons older than 45 years. Among the possible causes of increased susceptibility to type 2 diabetes are such schizophrenia-associated conditions as impaired glucose tolerance, overweight, obesity, inadequate nutrition, lack of exercise, and inadequate self-care. Other obstacles to good health care among patients with schizophrenia include impaired communication ability, denial of illness, social withdrawal, and undertreatment because of comorbid conditions. Different antipsychotic medications may also contribute to preexisting insulin resistance or glucose intolerance. Clinicians can optimize care by understanding the most significant barriers for each patient and incorporating this knowledge into an active treatment plan.

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Deaths from colorectal carcinoma (CRC) have diminished in recent years; the absolute annual decrease is 1.5% per year.

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A 47-year-old man with HIV infection presented with progressive dyspnea and worsening productive cough for the past 3 weeks. He also reported increasingly purulent sputum production. The patient reported being adherent to his antiretroviral regimen, and he had an admission CD4+ cell count of 550/μL. He did not have any previous opportunistic infections, and he denied any drug or tobacco use, recent travel, and ill contacts.

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A 58-year-old man with a past medical history of chronic sinus disease and hypothyroidism presented with left periorbital pain and erythema that worsened despite outpatient treatment with topical antibiotics. An outpatient CT scan showed pansinusitis and orbital stranding. The diagnosis was orbital cellulitis and sinusitis.

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The differential diagnosis forendobronchial lesions includesbut is not limited toneoplastic causes, benign tumors,infections, and foreignobjects. We report a case of anunusual cause of endobronchiallesions.

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Disseminated echinococcal disease can present complex management issues that require a multidisciplinary approach to care. We describe a patient with hydatid disease who had multiple cysts in the liver, lungs, and pulmonary artery that were caused by Echinococcus granulosus infection.

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More than 22,000 persons in the United States are affected bycatscratch disease (CSD) annually. Despite the discovery of thecausative organism more than a decade ago, much is still unknownabout this illness. Recent data suggest that ticks, as wellas cats, may transmit the disease to humans. Immunofluorescenceassay is proving to be the most efficient and noninvasivetechnique for diagnosing CSD. Among available antimicrobials,azithromycin has proved to be especially useful, although randomized,double-blind, placebo-controlled trials are warrantedto define the best treatment method for patients with CSD.[Infect Med. 2008;25:242-246, 250]

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Telltale skin lesions of syphilis, gonorrhea, human papillomavirus infection, and Haemophilus ducreyi infection.

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A 26-year-old woman presented with a1-week history of pleuritic chest painand abdominal pain, which was associatedwith nausea but unrelated tofood intake or bowel movements. Shehad also had gross hematuria for thepast 10 days and swelling around hereyes and ankles as well as fatigue andarthralgias for 2 weeks.

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ABSTRACT: Syncope is often benign and self-limited; however, it may sometimes indicate a life-threatening condition. Advanced age, heart disease, and abnormal ECG findings are associated with potentially adverse outcomes. The initial evaluation, which consists of a careful history taking, physical examination, and ECG, often suffices to make the diagnosis. Neurally mediated disorders, the most common cause of syncope, are usually benign. Cardiac syncope, which usually requires admission and further assessment, may result from rhythm disturbances or from outflow obstruction attributable to structural or pathophysiologic mechanisms. Patients with cardiac syncope may be evaluated with echocardiography, Holter monitoring, stress testing, loop event recorders, or electrophysiologic studies. Other causes of syncope include orthostatic hypotension, use of certain medications, a primary neurologic disorder, and psychiatric disturbance. A significant number of patients have unexplained syncope.

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Asthma 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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THE CASE: A 7-year-old boy has had left ankle pain for 2 days. Neither he nor his mother can recall any recent trauma to the joint. He is usually very active, but he has been unable to bear weight on the left foot and has been resting in bed. His mother reports that he had some tactile fevers, which were transiently relieved with ibuprofen, and that he has been eating and drinking normally. Despite the application of ice and elevation, the ankle has become red and swollen.

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This is a very distinct, rare, and remarkable hemorrhagic rash, first recognized in 2006, with 7 known cases reported in the literature.

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A large randomized trial showing no effect of antibiotics on acute rhinosinusitis in adults does not inspire a change in recommendations for family physicians.

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Primary care physicians can take the lead in helping address these additional comorbidities in their patients with asthma.

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Pediatric ECGs vary by age;tracings change considerablyfrom birth through adulthood.In the ECG tracing above, theT waves are inverted. Nevertheless,as we outline here, the tracingis normal in a 9-year-old child; theT waves may not revert to normaluntil he reaches puberty.

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Migraine is an episodic, often debilitatingcondition that affects women moreoften than men. Twenty-eight millionAmericans suffer from migraineheadaches-and nearly 75% of theseare women.1 Unlike other chronic painconditions, migraine has its peakprevalence during the years of greatestproductivity, when most women arejuggling family responsibilities andcareers.2 Many women are particularlysusceptible to migraine attacks justbefore and during menses.

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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.

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A 13-year-old girl of African American descent is brought to the pediatrician’s office becauseof a lesion on her neck. The girl’s mother had telephoned the office before the visit, statingthat the lesion resembled a blister at first, but now looked like a burn.

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A 43-year-old woman was hospitalized with a 3-day history of fever and back pain. She was malnourished and seropositive for HIV infection. Results of blood and sputum cultures were negative. A community-acquired pneumonia was diagnosed. Chest film findings and the clinical presentation were inconsistent with Pneumocystis carinii pneumonia.

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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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In his second podcast, Dr Louis Kuritzky discusses the classes of incretin-based therapies now available for patients with type 2 diabetes mellitus.

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A 62-year-old obese woman with adult-onset type 1 diabetes mellitus had a 6-year history of bilateral leg edema. During the last year, the edema worsened and the skin on her legs thickened. She also had multiple, bilateral, painful, superficial ulcers that drained copiously.

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A 72-year-old man presented after several months of dyspepsia and 1 day of hematemesis. He was not taking NSAIDs.