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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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Fever and Rash: Infection or Kawasaki Syndrome?Kawasaki syndrome (KS) is a common and serious disorderthat most often affects children aged 1 to 8 years but mimicsa range of other diseases of childhood. Diagnosis of KS isbased on physical examination findings coupled with theexclusion of other causes. To provide optimal care for patients,it is important to be aware of the differential diagnosis of KS.We report a case of a 4-year-old boy who presented withpersistent fever and cervical lymphadenitis; later, mucousmembrane changes, rash, and conjunctival injectioncharacteristic of KS developed. [Infect Med. 2008;25:320-322]
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Palmar ErythemaThe significant palmar erythema seen on the hands of a 60-year-old man with alcoholic cirrhosis is a sign of underlying chronic liver failure.
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Would you Know Measles if You Saw It?A case of measles is a very rare diagnosis in the 21st century, but as MMR vaccination rates fall, the cases climb. Would you recognize the signs & symptoms?
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Esophageal Foregut Cyst Presenting as Suprahilar MassA chest roentgenogram from a 42-year-old man with asthma, primary hypoparathyroidism, and pectus excavatum showed a left suprahilar mass-like density.
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Achalasia in a Previously Healthy Young ManFor 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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Case In Point: Silicone-induced pneumonitis in a transgendered patientThe authors describe the development of pneumonitis in a patient who had initially presented with edema of the lower extremities. Biopsy results supported the conclusion that the pneumonitis was caused by silicone injections the patient had received 5 years earlier.
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Medication Persistence and Health Care Expenditures in a Managed Medicaid Population With AsthmaA retrospective review of administrative claims data was conducted to identify health plan members with asthma who were persistent with their controller medications and those who were not persistent. Utilization of health care services and associated costs were measured for both groups. Non-persistent use of controller medications resulted in more asthma-related emergency department visits and home health services whereas persistent controller use was associated with more physician office and outpatient visits. Mean asthma-related medical costs per member were greater in the non-persistent cohort ($577.62) than in the persistent cohort ($323.03). These findings support the need for targeted interventions to address non-persistence in a managed Medicaid population.(Drug Benefit Trends. 2009;21:112-118)
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Identifying the predictors of asthma-related deathDeath caused by asthma is not traditionally thought to be especially common, but it is important to note that asthma often plays a contributing and probably unrecognized role even if it is not often listed as the cause of death on a death certificate. Because early response to asthma exacerbations can make a crucial difference, it is important to develop patient action plans in the outpatient setting well before an attack occurs. However, since busy clinicians must prioritize their educational efforts, identifying who is most at risk for death from asthma is all the more important.
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Middle-Aged Man With Light-Headedness, Nausea, and PalpitationsA 44-year-old man presents to the emergency department (ED) with light-headedness, nausea, and vomiting of 1 day's duration. He has also had intermittent palpitations but denies chest pain, dyspnea, and weakness.
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Acute Gouty Arthritis and Gouty TophusA 5-day history of pain and swelling in the right third finger (A) were the complaints of a 76-year-old man. A few days earlier, another physician had prescribed indomethacin, 25 mg tid, but it had not helped, and the patient believed that his condition had worsened. He had had an attack of gout 5 years before but had not been taking any maintenance medication. The distal interphalangeal (DIP) joint of the affected finger was now erythematous and tender, with chalky subcutaneous deposits. A diagnosis of acute gouty arthritis and gouty tophus was made.
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Young Woman With Back, Abdominal, and Shoulder Pain After AssaultA 1-year-old woman comes to theemergency department (ED) 3hours after a male friend punched herin the left lower back. The blowknocked her to the floor and madeher feel faint. She also noticed bloodin her urine when she voided athome after the injury.
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Glioblastoma MultiformeA 57-year-old man was brought to the emergency department with severe bifrontal headache, which he had had for 3 weeks. Family members reported that the patient exhibited episodes of confusion and loss of recent memory since the onset of the headache.
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Sixth Lumbar VertebraAfter 6 weeks of persistent low back pain, an overweight 72-year-old woman sought medical evaluation. There was no history of trauma.
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Using Passive Measures to Improve Patient Medication AdherenceAdherence is a complex behavioral process strongly influenced by environmental factors. Six posters designed to improve medication adherence were displayed in a medical clinic, with each poster displayed for 1 month. These posters were seen by clinic patients but, as passive measures, required no additional time on the part of clinicians. Medication adherence to antidepressant therapy was assessed for two 18-month periods. Days of therapy and median gap (the number of days a patient goes without medication before filling the next prescription) were similar between the periods. Medication possession ratio (MPR) was increased in the intervention period (0.974 vs 0.994 days). During the 6-month period that the adherence posters were displayed, persistence decreased by only 10% (versus 22% for the nonintervention period). Use of passive measures may improve patient medication adherence. In this prospective study, both the MPR and persistence were improved. (Drug Benefit Trends. 2008:20:17-24)
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Obesity: Is There Effective Treatment?In this article, we review the factors that contribute to obesity. We then describe effective approaches to weight control, including exercise, dietary modification, drug treatment, and bariatric surgery.
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New Treatments for Early and Late COPD: Part 1, PreventionABSTRACT: The key factor in reducing morbidityand mortality in patients with chronicobstructive pulmonary disease (COPD)continues to be smoking cessation. Newerformulations of nicotine replacementtherapy-a nasal spray and an inhaler-provide rapid delivery of nicotine and maybe appropriate for highly dependent smokers.Bupropion has been shown to improvesmoking cessation rates, either when usedalone or with a nicotine patch. Both theinfluenza and pneumococcal vaccines arerecommended to reduce the morbidity andmortality associated with respiratory infectionsin patients with COPD.
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Preventing Reinfarction: Recommenations for a Heart-Healthy LifestyleABSTRACT: In addition to appropriate pharmacotherapy and assistance with smoking cessation, a secondary prevention plan should include counseling about a heart-healthy diet, a structured exercise program and/or increased physical activity, and assessment of psychosocial risk factors, such as depression. Advise patients to reduce their intake of salt, sugars, refined carbohydrates, and saturated and trans fats; incorporate more fruits, vegetables, and fish into their diet; and balance caloric intake and physical activity to achieve and maintain a body mass index between 18.5 and 24.9 kg/m2. Cardiorespiratory fitness is the key to cardioprotection; the threshold for improving it in persons with coronary heart disease is about 70% of the mea-sured maximal heart rate. Encourage patients to engage in multiple short bouts of physical activity daily, such as taking the stairs instead of the elevator or walking the dog. Among previously sedentary persons, this approach has effects on cardiorespiratory fitness, body composition, and coronary risk factors similar to those of a structured exercise program.
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Meeting the Challenge of New Infectious Scourges: MRSA, C difficile BI/NAP1, and New Strains of STD PathogensWithin the past decade, the incidence of methicillin-resistantStaphylococcus aureus (MRSA) has increased significantly,spreading from the hospital to the community setting. Patientswith skin infections whose condition is stable should be treatedwith antibiotic therapy as well as with incision and drainage,whereas patients with severe disease require hospitalizationand intravenous therapy. In addition to community-acquiredMRSA, a new strain of Clostridium difficile, BI/NAP1, has led toclinical challenges in infectious diseases medicine. The strainhas been associated with recurrent infection; more severe diseasethat mandates urgent colectomy; and dramatically highermortality in vulnerable populations, such as older adults. Oralvancomycin, rather than metronidazole, may be slightly moreeffective in patients with severe disease. Also, new strains of Chlamydia and Treponema are posing potential complications tothe treatment of sexually transmitted diseases such that cliniciansneed to be judicious in selecting antibiotic therapy in accordancewith factors related to geography and patient population.[Infect Med. 2008;25:421-424]
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Do You Recognize These Disorders?An 18-month-old girl presents with a mass in the lateralupper right orbital area (lateral brow). The lesion can bepalpated beneath the eyelid just inside the lateral aspect ofthe orbital rim. The lesion does not appear to interferewith the girl’s vision. The extraocular movements all appearnormal and, grossly, the child appears to visualizenormally with her right eye. CT reveals a well-circumscribed,cystic mass without bony involvement or deep intracranialextension.
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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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Hemoptysis: Benign or Not?Historically, tuberculosis (TB) was the most commoncause of hemoptysis. Classic operas, such asLa Traviata and La Bohème, featured dramatic scenes ofhemoptysis, often with the heroine dying following episodesof deep passion and coughing.
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What Do These Images Reveal?A 64-year-old woman presentsto the emergency department withworsening crampy abdominal painthat began the night before. Afterthe pain started, she had a bowelmovement containing a significantamount of blood; since then she hashad episodes of diarrhea. She hadbeen previously healthy, denies traumaand fever, and knows no one withsimilar symptoms. She reports norecent enema, endoscopy, or otherabdominal procedure.
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What Caused Cough and Hemoptysis in a Patient Recently Treated for Exudative Tonsillitis?A 22-year-old man presentedwith a 3-week history ofcough and hemoptysis withright-sided chest pain and decreasedoral intake associated with a 4.5-kg(10-lb) weight loss. Ten days beforehospital admission, he was involvedin a fistfight, which resulted in his arrest.He was taken to jail and placedin a holding cell for 3 hours. Shortlybefore his pulmonary symptoms developed,he was seen by his primarycare physician because he had a sorethroat and exudative tonsillitis, forwhich amoxicillin/clavulanate wasprescribed. He stopped taking theantibiotic after 3 days.
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Middle-aged Man With Chest PainFor 3 days, a 42-year-old man has had episodic dullchest pain. The anterior precordial and retrosternalpain intensifies with inspiration and movement. He has nohistory of recent viral infection, hypertension, coronaryartery disease, cardiac surgery, diabetes mellitus, or hyperlipidemia.There is no family history of cardiovasculardisease.
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A man with cough and dyspneaThe case presented here illustratesthe diagnostic challengesand potential severity of a fungalinfection.
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Man With Progressive Induration of the Skin and PruritusA disorder similar to scleromyxedema, nephrogenic fibrosing dermatopathy, has been reported in patients receiving renal dialysis. Lichen myxedematosus, an atypical form of papular mucinosis, is not associated with sclerosis and paraproteinemia; however, it may represent an early presentation of scleromyxedema.
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Anxiety Disorders:Millions of Americans suffer from anxiety disorders. Many with panic disorder, social anxiety disorder, and/or generalized anxiety disorder present initially to their primary care clinician. Effective treatment is possible in a busy primary care setting; therapy involves patient education and pharmacotherapy. Once other potential causes of symptoms of an anxiety disorder have been ruled out, the first step is to reassure the patient that he or she has a psychological condition-a very common one-and that symptoms are not the result of an undiagnosed disease or "going crazy" or "losing control." Educate and inform patients that complete clinical remission is achievable, often with medication alone. Begin treatment on day 1 with a long-acting benzodiazepine-such as alprazolam XR or clonazepam-or with the anxiolytic agent buspirone; at the same time, start a selective serotonin reuptake inhibitor (SSRI). The anxiolytic agent allays acute somatic symptoms until the full effects of the SSRI are manifest (often 4 to 6 weeks). The anxiolytic can then be gradually tapered. Referral to a psychiatrist for psychotherapy may be indicated when a patient refuses or cannot tolerate drug therapy, or when response to therapy is inadequate.
