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The rash of tick tularemia is seen here on the arm of a 5-year-old boy. He also had a tick bite on his back that became necrotic and ulcerated. Within 2 weeks of his having been bitten, axillary lymph nodes developed.

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ABSTRACT: Angiotensin-converting enzyme inhibitors and ß-blockers are the cornerstone of heart failure medical therapy; unless contraindicated, start these agents as soon as possible after volume status has been optimized. Aldosterone receptor antagonists, angiotensin-receptor blockers, and a fixed-dose combination of hydralazine and isosorbide dinitrate (the last recommended especially for African Americans) can be used as add-on therapy. Prophylactic implantable cardioverter defibrillators reduce long-term mortality in symptomatic patients with a left ventricular ejection fraction (LVEF) of 35% or less. Cardiac resynchronization therapy improves symptoms and ventricular remodeling in some patients; indications include wide (more than 20 milliseconds) QRS complex on ECG, impaired LVEF (35% or less), and advanced heart failure symptoms (NYHA classes III and IV) despite optimal drug therapy. Measurement of natriuretic peptides and impedance cardiography both show promise for monitoring patients with heart failure and for guiding therapy, but definitive data to justify their routine use are still lacking.

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This lesion had erupted on the back of an elderly man with diabetes mellitus. The inflammatory process involved contiguous follicles with pus evident at several openings.

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A54-year-old white woman presentswith extremely tender,firm lesions on the right hip and legsthat have been increasing in size andnumber over the past few months.

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For 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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For 2 years, a 60-year-old woman with long-standing hypertension had experienced worsening dizzy spells, fatigue, and chest discomfort. She also had cold extremities, significant dyspnea on exertion, and orthopnea. The patient was taking amlodipine and furosemide.

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Osteoporosis is no longer consideredage- or sex-dependent, although prevalencevaries by sex and race. Postmenopausalwhite women suffer almost75% of all hip fractures and havethe highest age-adjusted rate of fracture.Thanks to progress in our understandingof causes and treatments, thisdisease is largely preventable, and significantimprovements in morbidityand mortality are possible. The beststrategy for prevention and treatmentuses a team approach that involves thepatient, physician, health educators, dietitians,and physical therapists.

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This 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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Brief exposure to a variety of modifiable factors-physical and psychosocial-increases the risk of back pain.

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Actinomyces odontolyticus isa rare cause of pleuropericardialinfection, with only 1 caseidentified in the literature. Inthat instance, the infectionwas believed to be secondaryto gastric surgery. We present apatient with pericarditis andpericardial tamponade causedby A odontolyticus. The infectionoccurred after an ultrasound-guided subcarinalbronchoscopic needle biopsyperformed for a suspicious mediastinalmass found on a CTscan of the chest. We describethe case presentation, the microbiologyand treatment of Aodontolyticus infection, andthe classic features of pericarditisand cardiac tamponade.

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Abstract: Bridging anticoagulant therapy is used to minimize the risk of thromboembolic complications when warfarin therapy must be temporarily interrupted because of surgery or another procedure. The decision to use this strategy depends on the patient's risk of thromboembolic complications and the risk of bleeding associated with the specific procedure. One approach is to withhold 4 or 5 daily doses of warfarin before surgery and initiate low molecular weight heparin (LMWH) 3 or 4 days before surgery. The last dose of LMWH is administered at least 24 hours before the procedure. After the procedure, prophylactic-dose LMWH can be administered subcutaneously once daily. The use of therapeutic-dose LMWH should be deferred until at least 24 or 48 hours after procedures that have a low or moderate risk of bleeding and until 48 or 72 hours after high-risk procedures. (J Respir Dis. 2005;26(4):170-172)

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Many patients find cognitive behavioral therapy effective for management of their insomnia, but there aren’t enough clinical psychologists trained in the area.

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Lhermitte-Duclos disease is a rare, slow-growing, benign lesion of the cerebellum and is considered a hamartomatous tumor of the cerebellar cortex.

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A 3-day history of intermittent fainting spells brings a 49-year-old man to youroffice. His only significant medical history includes seasonal allergic rhinitis,for which he takes terfenadine, and mild depression, which is being treatedwith amitriptyline. A week ago, he began taking erythromycin, 500 mg qid,for acute pharyngitis.

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This 15-year-old boy presented with a 3-year history of gradual, bilateral breast enlargement. He was otherwise healthy and showed normal pubertal development.

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

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For 2 days, a 49-year-old man with hypertension and hypercholesterolemiahas experienced light-headedness and fatigue.Based on the presenting ECG, what is the most likely cause of hissymptoms?A. Accelerated junctional rhythm.B. First-degree atrioventricular (AV) block.C. Mobitz type I (Wenckebach) second-degree AV block.D. Mobitz type II second-degree AV block.E. Third-degree AV block (complete heart block).

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Chest pain at rest brought this 42-year-old man to the ED. He had experienced the pain in the past but only on exertion. He appears well on arrival. What does the ECG show?

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A total of 50 health care professionals, including 25 health plan medical directors, 20 health plan pharmacy directors, and 5 pharmacy directors for pharmacy benefit management companies were surveyed regarding their perceptions of the value of 3 novel cancer therapies. The physicians and pharmacists were asked to estimate the monthly average wholesale price of each therapy, overall survival benefit of bevacizumab for treatment of persons with advanced colorectal cancer and erlotinib for treatment of persons with non–small-cell lung cancer, and progression-free survival benefit of sunitinib malate for treating persons with advanced renal cell carcinoma. Most respondents overestimated drug costs and underestimated survival benefit associated with these treatments. Mean incremental cost-effectiveness ratio for all drugs studied was approximately $170,000/quality-adjusted life-year (QALY). Cost-effectiveness ratios were lower than the $300,000/QALY cited by oncologists in another study but significantly higher than those for many other costly interventions. Our study findings reflect the need for a better understanding of the value of the clinical benefits of novel cancer therapies in an environment of product innovation but with resource constraints. (Drug Benefit Trends. 2009;21:120-130)

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Most of the symptoms of allergic rhinitis, including nasal obstruction, rhinorrhea, sneezing, and nasal itching, respond to intranasal corticosteroids administered once or twice daily. However, many patients also need to take an antihistamine for adequate control of symptoms. While an antihistamine/decongestant combination can provide symptomatic relief, it fails to address the inflammatory component of allergic rhinitis. Thus, combining an intranasal corticosteroid or oral leukotriene modifier with an antihistamine might be a more effective strategy. Factors that can facilitate treatment adherence include minimizing the number of daily doses, allowing patients to select their own dosing schedules, and providing written instructions. Specific immunotherapy can be beneficial in select patients whose allergic rhinitis symptoms are not sufficiently controlled by pharmacotherapy. (J Respir Dis. 2005;26(5):188-194)

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Consider this diagnosis when a patient presents with a history of rapid, diffuse hair loss. Telogen effluvium affects the entire scalp, but the crown and bitemporal areas may appear to be mainly involved if there is associated androgenetic alopecia.

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This lesion looks suspiciously like a malignant melanoma.

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The follow-up risk of death or an ischemic cardiovascular event that requires hospitalization is about 10-fold higher than the risk of hospitalization for major bleeding.

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The patient describes acute onset of chest pain with nausea and diaphoresis. The cardiac and pulmonary examinations are normal. What does the 12-lead ECG reveal?

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Allergic disorders are becoming more common. For example, about 20% of Americans have allergic rhinitis, which accounts for more than 10 million office visits each year. Most of these visits are to primary care clinicians.

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This 64-year-old woman has had rheumatoid arthritis for 15 years; her hands show classic rheumatic changes. She also had a leg ulcer that had failed to heal in 8 years despite three skin grafts.

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If a patient has had 2 appropriately administered doses of measles-mumps-rubella (MMR) vaccine and has a nonimmune response on a rubella titer (required in all pregnant women in Louisiana), should another dose of MMR vaccine be given? Is there any evidence that this would provide immunity to rubella?

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After cimetidine was releasedin the late 1970s,case reports of clinicallysignificant drug interactionsquickly emerged.1-3Controlled trials soon validated theseinitial clinical observations. Since1983, when a comprehensive reviewof cimetidine drug interactions waspublished,4 more interactions havebeen reported, as use of this agenthas increased because of cost constraintsand the rapid growth of managedcare. Examples of well-documentedinteractions are listed in theTable.

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The authors describe a woman who presented with severe pulmonary hypertension. A cardiopulmonary cause was initially sought, but thyrotoxicosis was the underlying cause.