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Research Focus: Recent Developments in HIV TherapeuticsResearch Focus: Recent Developments in HIV Therapeutics
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How best to diagnose and control asthma in the elderlyAbstract: A number of factors can complicate the diagnosis of asthma in elderly patients. For example, the elderly are more likely to have diseases such as chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) that--like asthma--can cause cough, dyspnea, and wheezing. Spirometry can help distinguish asthma from COPD, and chest radiography and measurement of brain natriuretic peptide levels can help identify CHF. Important considerations in the management of asthma include drug side effects, drug interactions, and difficulty in using metered-dose inhalers. When discussing the goals of therapy with the patient, remember that quality-of-life issues, such as the ability to live independently and to participate in leisure activities, can be stronger motivators than objective measures of pulmonary function. (J Respir Dis. 2006;27(6):238-247)
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SSRIs and Triptans: Safe as Combination Therapy?Depression was diagnosed 6 years earlier in a 37-year-old woman; it has been successfully managed since then with fluoxetine and outpatient psychotherapy. Since her teenage years, the patient has also experienced sporadic (fewer than 3 or 4 per year) mild or occasionally severe headaches, which she has usually self-treated with over-thecounter (OTC) agents or "just slept off."
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Emphysematous Pyelonephritis Caused by Pasteurella multocidaEmphysematous pyelonephritis (EPN) is a rare but life-threatening infection characterized by widespread necrosis and production of gas within the kidney.
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Gram-Negative Bacteria as Cause of Foot IntertrigoFor a year, a 31-year-old man had asymptomatic, malodorous discoloration of the toe web spaces. He stated that his feet perspire heavily in the boots he is required to wear for work.
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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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Survival in ALS Plus FTD Influenced by Timing of Symptom OnsetWhat is the prognosis for patients with frontotemporal dementia and motor neuron disease? A new study suggests the answer depends not on which occurs first, but whether cognitive and motor symptoms develop simultaneously.
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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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Research-Based Approaches to Treating Alcohol Use in Primary CareWhen it comes to generating high-quality evidence applicable to clinical care, the alcohol field has lagged behind other medical-scientific fields, according to Dr Richard Saitz, a recent presenter at Yale University Medical School. Dr Saitz is Professor of Medicine and Epidemiology and Director, of the Clinical Addiction Research and Education (CARE) Unit Section of General Internal Medicine, at Boston University Schools of Medicine and Public Health.
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Bilateral Mandibular FracturesA 20-year-old man sustained a 2- to 3-cm soft-tissue laceration in the middle of the chin when he fell, face forward, onto pavement.
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Anal Atresia in a NeonateA newborn male is seen with anal atresia. Isolated finding? Or, first clue?
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BRCA: A Primary Care Concern?October is Ovarian Cancer Awareness Month. Find out in this podcast with Harvard professor Richard Penson, MD, what traits in your female patients should prompt testing.
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Intoxication with street drugs: Cocaine and amphetaminesCocaine and amphetamine intoxication continue to be common causes of emergency department and hospital admissions.
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Woman With Daily Headaches That Have Become Refractory to TriptansA 30-year-old woman complains that her headaches no longer respond to triptans; instead, they have increased in frequencyand severity. The pain interferes with her ability to work part-time and to take care of her 16-month-old daughter.
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Case In Point: A case of bilateral hilar lymphadenopathyThe authors describe a rare cause of diffuse thoracic lymphadenopathy--Cogan syndrome. This case was remarkable for the temporal development of extensive lymphadenopathy independent of other hallmark symptoms and signs of this syndrome. In the appropriate clinical setting, Cogan syndrome should be considered in the differential diagnosis of thoracic lymphadenopathy.
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Zosteriform Lentiginous NevusA 17-year-old girl sought evaluation of multiple face and neck nevi. The lesions had been present at birth and were becoming darker as the teen grew older. She reported no family or personal history of skin cancer or dysplastic nevi.
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Are Guns a Health Issue?Confirmation of President Obama's nominee for Surgeon General is suspended as the debate over an answer to this question continues.
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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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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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Renal Artery Stenosis Complicating Essential HypertensionA 73-year-old man who had a history of long-standing essential hypertension, congestive heart failure, mild renal insufficiency, atrial fibrillation, and a mitral valve replacement presented with refractory hypertension. His medications included labetalol, irbesartan, and furosemide.
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Questions Physicians Often Ask About Allergens That Trigger AsthmaAbstract: Because of the impact of allergen exposure on asthma control, all patients with asthma should be evaluated for allergic sensitization. Such patients can be referred to an allergist for evaluation, or radioallergosorbent tests can be ordered by the primary care provider. The major groups of aeroallergens that can trigger asthma attacks include furred-pet, dust mite, cockroach, rodent, mold, and pollen allergens. When assessing a patient's exposure history, remember that furred-pet allergens are found not just in the home, but in other settings, such as schools, and these allergens are passively transferred from one environment to another. Allergen avoidance measures are essential to the management of asthma in sensitized patients and can significantly improve asthma control. First-line dust mite control measures include installing allergen-proof mattress and pillow encasements, washing all bedding every 1 to 2 weeks in hot water, removing stuffed toys, vacuuming and dusting regularly, and reducing indoor relative humidity. (J Respir Dis. 2006;27(12):511-526)
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Dermatoses of Childhood: 7 Photoclinic CasesCan you diagnose these 7 cases of dermatoses? Scroll through our Photoclinic to find out.
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Chronic Plaque PsoriasisChronic plaque psoriasis in this 37-year-old man was treated with systemic corticosteroids after topical medications proved ineffective. The corticosteroids provided initial relief, but the psoriasis recurred once the medication was discontinued. This patient had been in a county jail for about 18 months; during his confinement, he was not exposed to sunlight.
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Recognizing the impact of obstructive sleep apnea in patients with asthmaAbstract: The coexistence of asthma and obstructive sleep apnea (OSA) in a given patient presents a number of diagnostic and treatment challenges. Although the relationship between these 2 diseases is complex, it is clear that risk factors such as obesity, rhinosinusitis, and gastroesophageal reflux disease (GERD) can complicate both asthma and OSA. In the evaluation of a patient with poorly controlled asthma, it is important to consider the possibility of OSA. The most obvious clues are daytime sleepiness and snoring, but the definitive diagnosis is made by polysomnography. Management of OSA may include weight loss and continuous positive airway pressure (CPAP). Surgical intervention, such as uvulopalatopharyngoplasty, may be an option for patients who cannot tolerate CPAP. Management may include specific therapies directed at GERD or upper airway disease as well as modification of the patient's asthma regimen. (J Respir Dis. 2005;26(10):423-435)
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State-of-the-art airway imaging with CT: Part 3Abstract: A significant advance in CT imaging is the use of 3-dimensional (3D) reconstruction techniques. A 3D reconstruction, for example, permits a volumetric evaluation of the contours of the airways and displays areas of stricture, or narrowing, more effectively than do routine axial images. External 3D rendering, also called CT bronchography, helps reveal complex airway abnormalities and improves the detection of subtle airway stenoses. Although it is primarily an investigational tool, internal 3D rendering (virtual bronchoscopy) has several potential applications, including assessing airway stenoses, guiding transbronchial biopsy procedures, and screening for lung cancer. Multiplanar reformation imaging methods can aid in the assessment of airway stenoses, airway stents, tracheomalacia, and extrinsic airway compression. A review of multiplanar images can also aid in the planning of stent placement or surgery. (J Respir Dis. 2006;27(8):348-352)
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Anal Pain: Office Diagnosis and TreatmentPatients almost always believe that their anorectal problems are caused by hemorrhoids, regardless of the nature of their symptoms. They are often dismayed when we insist that they must come to the office for an examination before we can prescribe any treatment.
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Tympanic Membrane Perforation:An Unusual Complication of Varicella-Zoster Virus InfectionOtological complications associated with varicella-zostervirus infection are common; however, tympanic membraneinvolvement is rarely reported. We describe a patient withherpes zoster in whom hemorrhagic otitis media with tympanicmembrane perforation developed. To our knowledge,this is the first report of an HIV-infected patient with thisunusual presentation. [Infect Med. 2008;25:561-562]
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Catastrophic Antiphospholipid Syndrome in Secondary SyphilisCatastrophic antiphospholipid syndrome (CAPS), first described by Asherson and colleagues1 in 1992, refers to a clinical scenario in which multiple vascular occlusive events involving small vessels that supply blood to organs occur over a short period.
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Mediastinal Abscess From Laryngeal Mask AirwayThe laryngeal mask airway (LMA) has become a popularalternative to endotracheal intubation. Many cliniciansconsider it a safe procedure, but complications do occur.Although uncommon, retropharyngeal perforation withmediastinal abscess can become a life-threatening event. Wereport a case of mediastinal abscess in an 84-year-old womanwho received LMA ventilation during a surgical procedurefor total knee replacement. [Infect Med. 2008;25:180-185]
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Book Review: The Fifteen Minute Hour: Therapeutic Talk in Primary CareStress affects daily activities, influences the way symptoms are perceived, and detracts from quality of life; it plays a role in everyone’s life and is a component of every illness. The responsibility of the primary care physician is to help manage the stress and recognize when specific therapeutic measures are needed. The fourth edition of The Fifteen Minute Hour presents biopsychosocial approach concepts from the earlier editions of the book and provides new material to make the principles and techniques more useful to primary care health professionals.
