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Hand Injuries, Part 2:When you suspect blunt nerve trauma, referral to a hand surgeon is prudent-even without evidence of acute compartment syndrome. The same is true if you discover ischemia in any part of the hand after injury. Try to control hemorrhage with compression and elevation of the involved extremity. If this is unsuccessful, use a short-duration tourniquet. Do not attempt to clamp a bleeding vessel; the risk of causing serious nerve or tendon damage is too high. Avoid exploring wounds in the region distal to the midpalmar crease and proximal to the proximal interphalangeal flexor crease because of the high risk of damaging the flexor tendons and the annular ligaments in this region. Explore more proximal injuries cautiously to determine occult injury to the flexor tendon.
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COX-2 Inhibitor Therapy: When Is Monitoring Required?Q:Is periodic laboratory monitoring recommended for patients withosteoarthritis who are receiving long-term cyclooxygenase-2 (COX-2)inhibitor therapy and who have no GI or renal symptoms? Similarly,is laboratory monitoring recommended for women who take a selectiveCOX-2 inhibitor to alleviate menstrual cramps (eg, rofecoxib, 50 mg/d,3 to 5 days per month)?--Sarita Salzberg, MDColumbus, Ohio
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Drug Therapy in the Elderly:Numerous factors put elderly patients at risk for adverse drug events. On average, they take at least 6 medications a day, which increases the likelihood of drug-drug interactions. In addition, many drugs that are safe and effective in younger patients are inappropriate for older persons because of age-related changes and comorbid conditions that affect absorption, distribution, metabolism, and elimination. First-pass metabolism decreases with age, which may increase systemic absorption of some oral nitrates, ß-blockers, estrogens, and calcium channel blockers. The age-related rise in body fat increases the volume of distribution of lipid-soluble compounds, such as diazepam, and prolongs clearance. About two thirds of elderly persons have impaired kidney function; in these patients, the dosage of renally excreted drugs-such as digoxin-needs to be reduced. Other strategies for avoiding adverse drug events are detailed here.
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Invasive Fungal SinusitisWith advances in chemotherapy, transplantation, and the treatment of diabetes and HIV infection, fungal sinusitis has become increasingly recognized in patients in these at-risk groups.
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Man With Painful Shoulder AbscessFor 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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Psoas AbscessA 49-year-old woman with a history of alcoholic cirrhosis, esophageal varices, coronary artery disease, diabetes mellitus, and hypertension presented to the emergency department with a 2-day history of fever, chills, nausea, and back and abdominal pain. The pain began on the right side, progressed to the lower back, and radiated into the right anterior thigh and groin area.
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Case In Point: Coexisting Hodgkin disease and lung cancer in a patient with AIDSThe patient was a 41-year-old manwith a history of HIV infection diagnosed10 years before admission.He had been noncompliant withtreatment, and therapy with tenofovir,efavirenz, and lamivudinehad not been started until 2 monthsbefore admission, when he presentedto another hospital. At thetime, his CD4+ cell count was156/µL and his viral load was45,743 copies/mL. He also had ahistory of incarceration; had usedinjection drugs, cocaine, alcohol,and marijuana; and had a 20-packyeartobacco history.
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Chest Film Clinic: What caused persistent cough and dyspnea in this patient?A 65-year-old woman presented to her primary care physician with a 3-month history of worsening cough, now productive of copious blood-tinged secretions. She also reported a recent onset of fever and dyspnea. She denied any chest pain, chills, night sweats, and weight loss.
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The Obesity and Dementia LinkGrowing evidence suggests a link between obesity and dementia, but risk may be heightened or lowered, depending on age. In this study, early to mid-life obesity was linked with increased risk of later dementia.
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Obesity May Be Associated with Abnormal Bowel HabitsA recent study found that obese or severely obese patients have a 60% higher risk of chronic diarrhea vs those who are within a normal weight range.
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When to obtain cultures from patients with community-acquired pneumoniaAbstract: The use of sputum studies and blood cultures in patients hospitalized with community-acquired pneumonia (CAP) is somewhat controversial, and recommendations continue to evolve. A reasonable approach is to attempt to obtain sputum cultures from all patients before initiating antibiotic therapy. If antibiotics have already been given, sputum studies can be reserved for patients who are severely ill or who are at risk for infection with a resistant organism or an organism that is not covered by the usual empiric therapy. The Infectious Diseases Society of America and the American Thoracic Society both recommend obtaining blood cultures from all patients. However, cost considerations have led to alternative strategies, such as reserving blood cultures for those with severe CAP. (J Respir Dis. 2005;26(4):143-148)
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Lung IncidentalomaDuring the evaluation of a 61-year-old man who had sustained mild head and upper trunk injuries in a car accident, a right lower lobe consolidation was noted on the chest radiograph. There was no evidence of rib fracture. A chest CT scan with contrast showed a hilar mass that obstructed the lateral segmental bronchi of the right lower lobe. Atelectasis of the posteromedial segments of the right lower lobe and ipsilateral subcarinal adenopathy were also noted.
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Giant Bullous EmphysemaA 54-year-old man presented to the ED with palpitations identified as atrial flutter and RVR. Medical history included stage IV renal-cell carcinoma, end-stage COPD, NYHA class IV heart failure, and recent pulmonary embolism. A CT scan of the thorax was ordered.
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Persistent Headache in a Young WomanHeadache and nausea have bothered this 28-year-old for 3 days. Over-the-counter analgesics do not help. She reports the headache lessens during the day. What more do you need to know?
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Prevention as a Replacement for Breakdown MedicineMuch of health care today consists of treatment of disease. Few resources are allocated to prevent disease. Many treatments are not delivered optimally because of a lack of patient discipline and insufficient follow-up by physicians and other health care providers.
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Antimicrobial Resistance Update: Klebsiella pneumoniae CarbapenemasesThe rapid spread of Klebsiella pneumoniae carbapenemases (KPCs) is limiting the effectiveness of carbapenems in the treatment of multidrug-resistant infections. The resistance genes found in KPCs have been identified in other organisms as well and have properties that have raised concerns regarding their transmissibility and epidemic potential.
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Mycobacterium goodii Infection of a Total Knee ProsthesisMycobacterium goodii infection is uncommon and probablyoccurs via disruption of skin and bone integrity or theintroduction of a foreign body into viscera, namely implantationof a prosthetic device. We describe a case of nosocomial,total knee arthroplasty–associated M goodii infection thatrequired combined antibiotic and surgical therapy for clinicalmanagement. An infection control investigation revealed thatthe source of the organism might have been the water in theoperating room scrub faucets. [Infect Med. 2008;25:522-525]
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BMI Opens Door to Weighty DiscussionTo initiate a discussion with a patient about excess weight without causing embarrassment or offense, try reporting the patient's body mass index.
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Smallpox Vaccination: The Risks for Patients With Atopic DermatitisBecause of recent threats of bioterrorism, smallpox vaccination was reinstated in the United States earlier this year. Since January 2003, more than 35,000 civilian and public health care workers in 54 jurisdictions have been vaccinated.
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Disseminated Histoplasmosis in a Woman With History of Polymyositis and Possible DermatomyositisFor 3 days, a 28-year-old woman with a history of polymyositis and possible dermatomyositis had fever, chills, and nonproductive cough. She complained of rash, joint pain, and progressive immobility because of severe muscle weakness. For the past 6 years, she had been taking prednisone (60 mg/d), hydroxychloroquine (200 mg bid), and tramadol (100 mg q6h prn for pain).
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Diabetic Nephropathy:Diabetic nephropathy, the leading cause of end-stage renal disease (ESRD) in the United States, affects 20% to 30% of patients with diabetes. Early diagnosis and aggressive treatment may delay the progression of kidney disease.
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5 Top Medical Books of All TimeEvery healthcare provider has a stack of dog-eared sacred favorites they travel with, for life. This selection is based on one MD's annual assessment.
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Anxiety Related to Heart Disease Identified by QuestionnaireAfter a cardiac event, many patients experience psychiatric symptoms, including depression, but more recent studies have paid attention to anxiety.
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FDA Mulling Pricey Implant as Opioid Addiction TxDiscreet delivery of controlled-release buprenorphine could be a game changer in treating addiction--but only if its affordable.
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Varicelliform Lesions in a 9-Year-Old BoyA 9-year-old boy, who has no significantmedical history, presents with a generalizedpruritic eruption of 2 weeks’ duration.One week earlier, another practitionerruled out scabies and treatedhim presumptively for varicella.
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Psoriasis Therapy: What’s NewIn recent years, the role of the immunesystem in the pathogenesis of psoriasishas been extensively delineated. Thisresearch has spawned a new classof medications that target specific immunefactors and hold great promiseas psoriasis therapies. The Table highlightsthe significant features of 4 ofthese biologic agents.
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Bronchoalveolar Carcinoma in a 58-Year-Old ManA 58-year-old man presents with exertionaldyspnea of 6 weeks’ duration, adry cough for 2 weeks, and decreasedappetite. He denies fever, chills, sputumproduction, hemoptysis, cigarette smoking,and significant weight loss. Thepatient, a retired electrician, was exposedto asbestos 20 years earlier.
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Predictors of Response to HAART: Part IIAs treatments for HIV-1 infection have become more effective, better tolerated, and more conveniently administered, treatment success has increased, but many factors influence treatment response. In addition to issues concerning when to initiate HAART and how to optimize therapeutic potency, challenges related to resistance to antiretroviral therapy in treatment-experienced patients as well as patient demographics and adherence affect antiviral response. [Infect Med. 2008;25:294-298]
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Underarm Eruption in a Teenaged BoyTopical 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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Leiomyoma CutisThe red, 1- to 3-mm lesions on the right forearm of a 19-year-old man had recently become tender after being asymptomatic for 10 years. The patient described a shooting pain on palpation. Previous biopsy results showed no cancer. He had high blood pressure but was otherwise healthy. His father had similar lesions.
