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Considering the role of NPPV, PEEP, and other interventions Managing acute severe asthma: What therapies to try, part 2 key words: Asthma, Leukotriene modifiers, Mechanical ventilationabstract: The mainstay of therapy for acute severe asthma includes ß2-agonists, anticholinergics, and corticosteroids. Other agents, such as leukotriene modifiers and magnesium sulfate, can be used in patients who have responded poorly to conventional therapy. Noninvasive positive pressure ventilation (NPPV) should be tried before intubation in alert, cooperative patients who have not improved with aggressive medical therapy. However, NPPV should not be attempted in patients who are rapidly deteriorating or in those who are somnolent or confused. Endotracheal intubation is recommended for airway protection or for patients who present with altered mental status or circulatory shock. Patients should be admitted to the ICU if they have difficulty in talking because of breathlessness, altered mental status, a forced expiratory volume in 1 second or peak expiratory flow rate of less than 25% of predicted, or a PaCO2 greater than 40 mm Hg after aggressive treatment in the emergency department. (J Respir Dis. 2007;28(3):113-117)
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Antiretroviral TherapyTenofovir disoproxil fumarate is approved to treat HIV infection in combination with other antiretroviral agents. Although tenofovir is generally well tolerated, the potential for nephrotoxicity exists based on preclinical data, case reports, and observational studies.
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Preschooler With Slowly Progressing Rash on One ArmDuring the past week, a rash on theright thumb and forefinger of a 4-yearoldboy has progressed to involve theentire arm.
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Matters of the Heart: Pericardial TamponadeA 70-year-old woman with no previousmedical problems had had progressivedyspnea and generalized weaknessfor the past several days. She washypotensive (73/31 mm Hg), tachycardic(120 beats per minute), andtachypneic (28 breaths per minute);oxygen saturation (room air) via pulseoximetry was 84%.
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Pseudomembranous ColitisFollowing mechanical bowel preparation and prophylactic antibiotic therapy, a 59-year-old man underwent transanal excision of a villous adenoma of the distal rectum. Two weeks after discharge, he returned with a temperature of 38.9°C (102°F), abdominal pain, and diarrhea.
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Cutaneous Mycobacterium InfectionThis rash, which covered a 68-year-old woman's body, was noted to have worsened during the past 2 months. A cephalosporin antibiotic had failed to clear the condition. The patient, a nursing home resident, suffered from emphysema, asthma, and heart disease. She had been receiving oxygen therapy and prednisone for 1 year.
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Herpes ZosterApproximately 1 million cases of herpes zoster are diagnosed in the United States every year. Here, a refresher on the virus and a good look at the rash.
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What Is This Intensely Pruritic Rash?A 71-year-old woman presents to the emergency department for evaluation of a blistering, intensely pruritic generalized rash that started 5 days earlier. Multiple ruptured and intact hemorrhagic bullae are obvious on the hands, arm, neck, chest, back, and abdomen and to a lesser extent on the lower extremities. The mucous membranes are spared. The Nikolsky sign is absent. The patient reports recent use of furosemide for periodic leg swelling.
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Preventive measures are still the best strategy Aspiration syndromes: Pneumonia and pneumonitis key words: Aspiration, Pneumonitis, Pneumoniaabstract: While the risk factors for aspiration pneumonia are similar to those for aspiration pneumonitis, the 2 syndromes have different presentations. Aspiration pneumonia tends to occur in older patients or in those with neurological diseases, and the aspiration is not usually witnessed. Aspiration pneumonitis is more likely to occur in patients undergoing anesthesia or in those with acute drug and alcohol overdoses, and the aspiration is often witnessed. The workup may include bedside assessment of the cough and gag reflexes, chest radiography, videofluoroscopic imaging, or fiberoptic endoscopy. Empiric antibiotic therapy should be avoided in most patients with pneumonitis; however, antibiotics may be indicated for those at high risk for bacterial colonization of oropharyngeal and gastric contents who have fever, increasing sputum production, or new infiltrates or for those who fail to improve within 48 hours. (J Respir Dis. 2007;28(9):370-385)
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Polymicrobial Wound Infection and Nerve Injury Secondary to a Nonhuman Primate BiteNonhuman primate bites in the United States are rare. Mostphysicians have no experience managing them. The lesionsare initially treated in much the same way as human bites,although consultation with an infectious diseases specialist,surgeon, and veterinarian are recommended, especially formicrobial infection control and management. Of particularconcern is animal-to-human transmission of herpes B virus,which can be fatal. We report a case of polymicrobial simianbite wound infection with associated nerve injury in a12-year-old boy. [Infect Med. 2008;25:120-122]
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Emerging Pathogens and New Recommendations in Travel MedicineMost travelers to third-world countries encounter healthrelatedproblems during their stay and may require medicalattention on returning home. Although malaria is still themost common diagnosis among travelers to the developingworld, several other infectious diseases, such as avian influenza,dengue fever, chikungunya fever, leishmaniasis, andmultidrug-resistant tuberculosis, are growing in importance.Clinicians need to stay informed about travel requirementsand vaccine recommendations for US citizens. [Infect Med.2008;25:352-386]
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Crossed Renal Ectopia With FusionFrequent urinary tract infections and unexplained hypertension (160/100 mm Hg) occurred in a 38-year-old man with no significant medical history. The heart and chest were normal; a right lower quadrant mass was detected in the abdomen. Red blood cells were found in the urine. An abdominal CT scan demonstrated that the left kidney was fused to the lower pole of the right kidney with the left pelvicaliceal system to the left of the midline; these findings are consistent with crossed fused renal ectopia. Cystographic and cystoscopic examinations were normal.
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After Metformin: Which Class Would you Choose?In this older patient with T2DM, HFpEF, and other comorbidities, which class of medication is most appropriate--and guideline-recommended?
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Woman With Acromegaly Presenting as Unilateral Vision LossA 36-year-old woman presented to the emergency department with loss of vision in the right eye that had initially involved the peripheral field and progressed over 2 months to the central and nasal fields. During this period, she also had headaches, vomiting, and generalized weakness. She had had amenorrhea for 1 year.
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AHA: Study Finds Celebrex Safe for HeartResults of the PRECISION study are embraced by some and soundly criticized by others. What would you tell your osteoarthritis patients?
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Pitfalls in Prescribing: Macrolide-Drug Interactions: Update on the Most Common and Clinically SignificantMacrolides are commonlyused to treat avariety of infections.Erythromycin haslong been recognizedas having numerous highly importantdrug interactions.1 Althoughclarithromycin generally has somewhatless of an effect on the clearanceof other drugs, it also has severalclinically relevant interactions.1-3
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Intraductal PapillomasSolitary intraductal papillomas are tumors of the major lactiferous ducts. They occur most frequently in women 30 to 40 years of age, and frequently present with nipple discharge.
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A patient with hemoptysis, anemia, and renal failureMicroscopic polyangiitis is a potentially fatal disease if it is notrecognized and treated early. In the case described here, what initiallypresented as a postinfectious residual cough was actuallyactive pulmonary hemorrhage, severe anemia, and a crescenticglomerulonephritis. Significant improvement was achieved withhemodialysis and aggressive treatment with corticosteroids andcyclophosphamide. This case exemplifies a classic presentationof microscopic polyangiitis and demonstrates the importance ofan expeditious diagnostic evaluation and early treatment to preventrapid deterioration. Early recognition and highly aggressiveimmunosuppressive treatment achieved significant suppressionof the disease.
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Mites and HTLV-1 at the Crux of a 10-Year Itch and Plaque-Like LesionsImmunosuppression that is associated with human T-cell lymphotropic virus 1 (HTLV-1) infection predisposes to hyperinfective strongyloidiasis.1,2
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Diagnosis of isolated axillary neuropathy in athletes: Case studiesCase studies of athletes with isolated axillary neuropathy provide an overview of this injury's anatomy and function, which are key to definitive diagnosis and appropriate treatment.
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Rhabdomyolysis Secondary to Urinary Tract Infection With E coliRhabdomyolysis is linked to infection in up to 31% of cases. However, only 19 cases of rhabdomyolysis related to E coli infection have been reported.
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Using ultrasonography in the diagnosis and management of pleural diseaseABSTRACT: The increasing availability of bedside ultrasonographyallows for more timely diagnosis and treatment of pleuraleffusion while limiting the patient's exposure to radiation. Thedynamic signs characteristic of pleural effusions includerespirophasic changes in the shape of the fluid collection, floatingmovements of atelectatic lung, and the plankton sign. Ultrasonographyalso is an efficient means of excluding pneumothoraxwhen rapid diagnosis is needed or after interventionssuch as central line placement, lung or pleural biopsy, or thoracentesis.The diagnosis of a pneumothorax relies on the absenceof dynamic signs such as "lung sliding." Static signs, suchas the comet tail artifact, or consolidated lung parenchyma orlung tissue that contains a solid mass, also can be useful in excludingpneumothorax. Ultrasonography can be used to guidefine-needle aspiration and core biopsies of pleural nodules,pleural thickening, and subpleural lung masses. (J Respir Dis.2008;29(5):200-207)
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Angiosarcoma of the FaceThe patient reported that he had noticed the facial eruption a couple of months earlier. On examination, the lesion appeared more plaque-like and dense than is typical of rosacea. The differential diagnosis included lupus, mycosis fungoides, rosacea, and angiosarcoma.
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Dyslipidemia: Effective Statin Treatment for Cardiovascular Disease PreventionDyslipidemia plays a dominant role in atherosclerotic plaque formation and as a modifiable risk factor for cardiovascular events.
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Using elastic compression stockings to prevent post-thrombotic syndromeThe reported incidence of postthrombotic syndrome (PTS) after a first episode of deep venous thrombosis (DVT) is quite variable, depending on the measurement scale used and the severity. Most studies suggest that the rate is 20% to 50%, with symptoms ranging from minor skin discoloration to chronic swelling and ulceration.1 However, the incidence of symptomatic PTS was less than 5% in a population of patients who underwent orthopedic hip and knee arthroplasty, regardless of whether they experienced symptomatic postoperative DVT.2
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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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“Mad Cow Disease”:What You-and Your Patients-Need to Know NowWhat is bovine spongiform encephalopathy(BSE), or “mad cow disease,” and how is itthought to infect cattle?
